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 4
- Culture of Safety 2
Education and Training
- Students 2
Error Reporting and Analysis
- Error Analysis 3
- Legal and Policy Approaches 1
- Logistical Approaches 2
- Quality Improvement Strategies 3
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 2
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 2
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medication Safety 2
- Psychological and Social Complications 3
Kaveh G. Shojania, MD; December 2007
An elderly woman undergoes surgery to repair a hip fracture. Even though formal preoperative assessment placed her at low risk, the patient suffers a pulseless electrical activity arrest during the operation and dies the next day.
- Spotlight Case
F. Daniel Duffy, MD; Christine K. Cassel, MD; October 2007
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
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.
- Spotlight Case
Lisa M. Bellini, MD; February 2004
Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies.
Tejal K. Gandhi, MD, MPH; October 2003
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
Elizabeth A. Flynn, PhD, RPh; September 2003
Failure to shake a bottle leads to a toxic level of carbamazepine in a patient being treated for seizure disorder.