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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- Communication Improvement 2
- Education and Training 2
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Logistical Approaches 2
- Quality Improvement Strategies 3
- Technologic Approaches 4
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 1
- Interruptions and distractions
- Medication Errors/Preventable Adverse Drug Events 4
- Spotlight Case
John Halamka, MD, MS; December 2011
While entering an order via smartphone to discontinue anticoagulation on a patient, a resident received a text message from a friend and never completed the order. The patient continued to receive warfarin and had spontaneous bleeding into the pericardium that required emergency open heart surgery.
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.
Jan Horsky, MA, MPhil; Vimla L. Patel, PhD, DSc; June 2005
An AIDS patient prescribed a combination medicine, including a drug she was already taking, narrowly misses being overdosed.
Robert L. Wears, MD, MS; September 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.
Harold S. Kaplan, MD; February 2004
Blood typing tubes for a married couple brought to an ED after a trauma are labeled with the opposite stickers. By coincidence, the wife's blood type was already on file. An alert blood-bank technologist catches the mistake.
- Spotlight Case
James G. Adams, MD; June 2003
Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.