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
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 1
- Human Factors Engineering 3
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 1
Kerm Henriksen, PhD; Kendall K. Hall, MD, MS; June 2011
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
Timothy S. Lesar, PharmD; November 2003
An unclear verbal order leads to administration of the wrong drug.
- Spotlight Case
Matthew B. Weinger, MD; George T. Blike, MD; September 2003
An infant acutely desaturates following an ED nurse's premature administration of a paralytic medication.
Mary Caldwell, RN, PhD, MBA; Kathleen A. Dracup, RN, DNSc; September 2003
A patient given diltiazem rather than saline suffers severe bradycardia requiring temporary pacemaker.