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 3
- Education and Training
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Teamwork 3
- Technologic Approaches 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 2
- Nonsurgical Procedural Complications 1
Jessica Katznelson, MD; September 2018
In a simulated cardiac resuscitation case of a 5-year-old boy found pulseless and apneic in the bathtub by a parent, many interprofessional teams had difficulty with resuscitation due to a lack of interoperability between the prestocked disposable laryngoscope blades and handles on the Broselow cart (a proprietary system designed to facilitate finding appropriate-sized equipment for pediatric patients requiring lifesaving interventions) with the emergency department's actual stock of blades and handles. This incompatibility led to significant delays and some failures to intubate. Teams often did not recognize the incompatibility and spent unnecessary time replacing batteries while others called for backup airway teams.
Jeffrey H. Barsuk, MD, MS, and Cynthia Barnard, MBA, MSJS; December 2014
In a simulation exercise conducted in an institution that felt it was prepared for patients with actual or suspected Ebola, a man presented to the emergency department with symptoms of nausea, vomiting, and fever. He had recently returned to the US from Sierra Leone. The nurse initiated an isolation protocol and the critical care team all donned personal protective equipment. During transport, confusion about which elevators to use potentially exposed 30 staff members to Ebola. Additional issues occurred including breaching sterile technique while inserting a central line and confusion about the process to transport the patient's blood to the lab.
Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Louis P. Halamek, MD ; December 2005
A resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor.
Mark A. Rosen, MD; November 2003
Due to the delay in anesthesiology becoming available for an urgent C-section, an infant is delivered with profound neurologic abnormalities.
- 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.