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 7
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Legal and Policy Approaches
- Quality Improvement Strategies 4
- Teamwork 2
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Safety 1
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 2
- Surgical Complications 4
- Health Care Executives and Administrators 7
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 5
Nancy Spector, PhD, RN ; March 2011
While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.
- Spotlight Case
Eric S. Holmboe, MD; February 2011
A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.
Caprice C. Greenberg, MD, MPH; October 2010
Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.
- Spotlight Case
Ernest J. Ring, MD; Jane E. Hirsch, RN, MS; October 2009
Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene.
Joan M. Teno, MD, MS; April 2008
Despite having a signed DNR (do not resuscitate) form, an elderly man brought to the emergency department with severe pain was rushed to the operating room for urgent abdominal aortic aneurysm repair.
James A. Yates, MD; March 2006
A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
Todd Sagin, MD, JD; March 2006
Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
D. John Doyle, MD, PhD ; July-August 2005
Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing.
Robert S. Wigton, MD; October 2003
Misplacement of an NG tube sends charcoal into the lung; the patient dies of complications.