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.
Volume Too Low: In and Out
- Spotlight Case
Marlene Miller, MD, MSc ; March 2011
Providers caring for an infant admitted with a viral infection and history of congenital heart disease failed to appreciate the significance of his low intake and output. The infant developed severe hypoglycemia and dehydration, and wound up in the pediatric intensive care unit.
Hold the tPA
Susan C. Fagan, PharmD, BCPS, FCCP; April 2005
A patient with presumed stroke is given tPA before the results of her coagulation studies are known. Five minutes later, the lab reports that the INR was elevated—an absolute contraindication to thrombolytic therapy.
Novel Drug Misuse
- Spotlight Case
Derek C. Angus, MD, MPH; Eric B. Milbrandt, MD, MPH; July 2004
Following a motor vehicle collision, a patient is mistakenly given drotrecogin alfa (activated) for organ failure not due to sepsis.