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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- Communication Improvement 2
- Error Reporting and Analysis 1
- Logistical Approaches 1
- Technologic Approaches 2
Robert L. Poole, PharmD; Tessa Dixon, PharmD; December 2010
Following a vehicle collision, a man admitted to the hospital was given a twofold overdose of dexamethasone, due to confusion about administration instructions on a multidose vial.
- Spotlight Case
Alan Forster, MD, MSc; December 2004
A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge.
Robert L. Wears, MD, MS; September 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.