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 3
- Education and Training
- Human Factors Engineering 2
- Logistical Approaches 2
- Quality Improvement Strategies 1
- Technologic Approaches 2
Clinton J. Coil, MD, MPH, and Mallory D. Witt, MD; September 2017
A woman developed sudden nausea and abdominal distension after undergoing inferior mesenteric artery stenting. The overnight intern forgot to follow up on her abdominal radiograph, which resulted in a critical delay in diagnosing acute mesenteric artery dissection and bowel infarction.
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.
- Spotlight Case
James G. Adams, MD; June 2003
Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.