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
- Culture of Safety 1
- Education and Training 3
- Human Factors Engineering 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Technologic Approaches 2
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medication Safety 2
- Nonsurgical Procedural Complications
- Spotlight Case
Benjamin S. Abella, MD, MPhil; Dana P. Edelson, MD; July-August 2007
A code blue was called on a man admitted for chest pain, but the defibrillation pads placed on the patient were incompatible with the machine.
Mark V. Williams, MD; July 2004
A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead.
- Spotlight Case
Mark Graber, MD; January 2004
A patient with chest pain is incorrectly diagnosed as having had an MI. Although physicians eventually realize the patient had an aortic dissection, it is too late. The patient dies.
Timothy S. Lesar, PharmD; November 2003
An unclear verbal order leads to administration of the wrong drug.
Herbert Y. Meltzer, MD; November 2003
Inappropriate use of IV haloperidol to manage psychosis in an AIDS patient causes polymorphic v-tach ("torsade de pointes"), necessitating a transvenous pacemaker.