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 4
- Culture of Safety 1
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Logistical Approaches 3
- Quality Improvement Strategies 2
- Specialization of Care
- Technologic Approaches 3
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Medical Complications 1
- Medication Safety 1
- Psychological and Social Complications 1
- Surgical Complications 1
Nita S. Kulkarni, MD; Mark V. Williams, MD; May 2008
An elderly patient seen in his primary care physician's office was stable but had a suspected heart failure exacerbation. The PCP chose to admit the patient directly to the hospital, to avoid a long emergency department stay. While in the admitting office awaiting an available bed, the patient deteriorated.
- Spotlight Case
Haya R. Rubin, MD, PhD; Vera T. Fajtova, MD; May 2004
To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic.
- 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.
Robert M. Wachter, MD; October 2003
A missing lab result leads to a 6-month delay in informing a patient about a new diagnosis of HIV.