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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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.