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
- Education and Training 1
- Human Factors Engineering 2
- Quality Improvement Strategies 4
- Technologic Approaches 2
- Device-related Complications 2
- Diagnostic Errors 1
- Medical Complications
- Medication Safety 1
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Nancy Moureau, BSN, RN, CRNI, CPUI, VA-BC; December 2012
A woman undergoing treatment for myasthenia gravis via PICC developed extensive catheter-related thrombosis, bacteremia, and sepsis, and ultimately died. Although the PICC line was placed at one facility, the patient was receiving treatment at another, raising questions about who had responsibility for the line.
Andrew S. Dunn, MD; April 2010
An elderly woman with a history of mitral valve replacement with a mechanical prosthesis was admitted to the hospital for evaluation of abdominal pain. Although an order was written to stop her blood thinner and restart it 48 hours after the procedure, the medication was not restarted.
Gurpreet Dhaliwal, MD; December 2009
Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.
William Hersh, MD; July-August 2007
A hospitalized elderly woman had clinical indications to receive medication to prevent venous thromboembolism. The intern noted this in the electronic record, and although this information was copied and pasted in the record on 4 consecutive days, the patient never received the intended prophylaxis and suffered a pulmonary embolism after discharge.
- Spotlight Case
Nils Kucher, MD; January 2006
Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.
- Spotlight Case
Adrienne G. Randolph, MD, MSc ; May 2003
An infant codes due to pulmonary emboli after a central line flush.