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.
Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis 3
- Human Factors Engineering 4
- Quality Improvement Strategies 3
- Specialization of Care 1
- Teamwork 4
- Technologic Approaches 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 3
- Medical Complications 1
- Psychological and Social Complications 1
- Surgical Complications
Richard A. Smith, DDS; July-August 2007
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
- Spotlight Case
Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH; May 2006
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Dennis S. O'Leary, MD; William E. Jacott, MD; December 2004
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
Marc J. Shapiro, MD; February 2004
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
J. Forrest Calland, MD; January 2004
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testiclewithout realizing that his right testicle had been removed previously.
- Spotlight Case
Charles Vincent, PhD; October 2003
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.
Andre R. Campbell, MD; April 2003
Laparoscopic colostomy completed in reverse induces total bowel obstruction.