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
Olle ten Cate, PhD; November 2018
An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.
Christopher Moriates, MD; January 2018
Following a positive fecal immunochemical test (a screening test for colon cancer), a colonoscopy was ordered for a 50-year-old man. Two months later, the nurse called him to see if he had obtained the colonoscopy. The patient reported that he was unable to schedule it due to cost of the copayment. The primary physician called the insurance company and was informed that the colonoscopy would be covered in full if the indication was written as preventive rather than diagnostic. Ultimately, the patient received the colonoscopy and was diagnosed with colon cancer 6 months after his initial positive screening test.