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
- Human Factors Engineering 2
- Teamwork 1
- Technologic Approaches 2
Robert R. Cima, MD, MA; September 2012
Following successful bypass surgery and mitral valve repair, an elderly man with diabetes, hypertension, and end-stage renal disease continued to attend hemodialysis and other clinic visits regularly. Eight months later, he was admitted to the hospital with shaking chills, confusion, and a collection of pus in his chest. A surgical procedure to free the trapped lung also uncovered a surgical instrument from the previous surgery.
Christopher R. Lee, MD; October 2009
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
- Spotlight Case
Eric J. Thomas, MD, MPH; Frederick A. Moore, MD; November 2003
A scrub nurse cannot find a missing suction catheter tip, but the surgeon closes the patient. A post-operative x-ray reveals the tip in the patient's chest.
Verna C. Gibbs, MD; September 2003
A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy.