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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Russ Cucina, MD, MS; April 2005
Thinking that the patient's glycemic control had spontaneously improved (and not realizing that the patient was continuing to receive long-acting insulin injections), a physician discontinues daily glucose checks and insulin sliding scale orders. Four days later, the patient is found unresponsive and hypoglycemic.