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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- 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.
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.