WebM&M Cases & Commentaries
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.
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B. Joseph Guglielmo, PharmD; May 2013
On multiple oral medications and a depot injection (dispensed by a separate specialty pharmacy and administered at a clinic), a patient with schizophrenia was mistakenly given the depot injection kit by his local pharmacy and injected it himself.
- Spotlight Case
Elisa W. Ashton, PharmD; February 2012
After entering an electronic prescription for the wrong patient, the clinic nurse deleted it, assuming that would cancel the order at the pharmacy. However, the prescription went through to the pharmacy, and the patient received it.