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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- Spotlight Case
John D. Halamka, MD, MS, and Deven McGraw, JD, MPH, LLM; July/August 2015
A hospitalized patient with advanced dementia was to undergo a brain MRI as part of a diagnostic workup for altered mental status. Hospital policy dictated that signout documentation include only patients' initials rather than more identifiable information such as full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. Because the order for a "brain MRI to evaluate worsening cognitive function" could apply to either patient, neither the bedside nurse nor radiologist noticed the error.
- Spotlight Case
Abigail Zuger, MD; June 2011
An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.
Daniel Mason, MD; September 2004
A medical student discovers that a hospital's radiology records are accessible via Internet, without any security, and struggles with whether and to whom to report the obvious HIPAA violation.
Stephen G. Pauker, MD; Susan P. Pauker, MD; May 2004
Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.
Colin F. Mackenzie, MD; March 2004
Video monitors near the operating room reveal a patient's identity, and gossip spreads about a very private issue.