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 9
- Culture of Safety 1
Education and Training
- Students 1
- Error Reporting and Analysis 1
- Human Factors Engineering 4
- Legal and Policy Approaches
- Logistical Approaches 3
- Quality Improvement Strategies 4
- Specialization of Care 1
- Technologic Approaches 4
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 4
- Identification Errors 1
- Interruptions and distractions 2
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 2
- Psychological and Social Complications 4
- Surgical Complications 4
Annie Yang, PharmD, and Lewis Nelson, MD; September 2016
Admitted for knee surgery, a man was given his medications at 10 PM, including oral dofetilide (an antiarrhythmic agent with a strict 12-hour dosing interval). In the electronic health record, "q12 hour" drugs are scheduled for 6 AM and 6 PM by default. Because the patient was scheduled to leave for the operating room before 6 AM, the nurse gave the dose at 4 AM. Preoperative ECG revealed he had severe QTc prolongation (putting him at risk for a fatal arrhythmia), and surgery was canceled.
Richard Rothman, MD, PhD; Sahael Stapleton, MD; May 2011
An emergency department worker develops chicken pox following an exposure during one of his shifts.
- Spotlight Case
Susan Barbour, RN, MS, FNP; December 2010
Admitted to the hospital with right-hip and left-arm fractures, an elderly woman remained on the same bed from the emergency department for nearly 16 hours and developed a moderate-sized, stage 2 pressure ulcer.
- 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.
Conrad V. Fernandez, MD; June 2007
A healthy woman who volunteered to participate in a radiology study was notified several weeks later of a "major abnormality" discovered on her MRI. She sought further evaluation and was diagnosed with uterine cancer.
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.
Daniel Mason, MD; September 2004
A medical student discovers that a hospital's radiology records are accessible via Internet, without any security, and struggles with whether and to whom to report the obvious HIPAA violation.
Darrell Campbell, Jr., MD; June 2004
Despite persuasion from a surgical resident that her mother's life was in danger, a patient's daughter refuses consent for surgery on her mother. This was wise, since the procedure was intended for a different patient with the same unusual surname.
Stephen G. Pauker, MD; Susan P. Pauker, MD; May 2004
Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.
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.
Colin F. Mackenzie, MD; March 2004
Video monitors near the operating room reveal a patient's identity, and gossip spreads about a very private issue.
Eran Kozer, MD; June 2003
A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.