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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Approach to Improving Safety
Death by PCA
Rodney W. Hicks, PhD, RN, FNP; February 2013
After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
Is the Admission Drug Dose Too Low?
Rainu Kaushal, MD, MPH; Erika Abramson, MD ; August 2009
The theophylline dose of a patient admitted for COPD exacerbation and pneumonia is doubled, and he develops atrial flutter with a rapid ventricular response, chest pain, and increased shortness of breath.
Moving Pains
- Spotlight Case
Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD; July 2006
An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.
One ACE Too Many
David N. Juurlink, BPhm, MD, PhD; July 2006
A patient presenting to the ED with chest pain was ruled out for MI, and discharged on an ACE inhibitor. Two weeks later, he returns with a critically elevated potassium level, has a cardiac arrest, and dies.
Impatient Inpatient Dosing
- Spotlight Case
Richard H. White, MD ; July-August 2005
An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding.
Bleeding Risk
Mark A. Crowther, MD, MSc; July 2003
Inadequate monitoring and management of warfarin places patient at significant risk of harm.