WebM&M Cases & Commentaries
Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 1
- Education and Training 2
- Human Factors Engineering 3
- Legal and Policy Approaches 2
- Logistical Approaches 2
- Specialization of Care 1
- Technologic Approaches 3
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems
- Interruptions and distractions
- Medication Safety 1
- Surgical Complications 1
- Spotlight Case
Christopher Fee, MD; February-March 2009
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
Mary K. Goldstein, MD, MS ; February 2006
Failure to enter documentation of a DNR order causes a severely ill elderly man to be resuscitated against his wishes. Shortly thereafter, the patient's wife confirms his wishes, and within minutes, the patient dies.
Tess Pape, PhD, RN, CNOR; February 2006
Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
Arpana Vidyarthi, MD; March 2004
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.