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 between Providers
- Sbar 1
- Communication between Providers 191
- Culture of Safety 27
Education and Training
- Students 5
Error Reporting and Analysis
- Error Analysis 48
Human Factors Engineering
- Checklists 44
Legal and Policy Approaches
- Regulation 12
- Logistical Approaches 38
- Policies and Operations 3
Quality Improvement Strategies
- Reminders 12
- Specialization of Care 29
- Teamwork 26
- Clinical Information Systems 94
- Alert fatigue 9
- Device-related Complications 48
- Diagnostic Errors 115
- Discontinuities, Gaps, and Hand-Off Problems 150
- Drug shortages 1
- Failure to rescue 2
- Fatigue and Sleep Deprivation 1
- Identification Errors 26
- Inpatient suicide 3
- Interruptions and distractions 20
- Delirium 4
- Medication Errors/Preventable Adverse Drug Events 112
- MRI safety 2
- Nonsurgical Procedural Complications 36
- Psychological and Social Complications 31
- Second victims 2
- Surgical Complications 58
- Transfusion Complications 4
- Ambulatory Care 70
- General Hospitals 216
- Long-Term Care 10
- Outpatient Surgery 8
- Patient Transport 4
- Psychiatric Facilities 7
- Allied Health Services 3
- Gynecology 64
- Cardiology 41
- Geriatrics 34
- Pulmonology 14
- Neurology 23
- Obstetrics 20
- Pediatrics 37
- Primary Care 32
- Radiology 19
- Nursing 49
- Palliative Care 6
- Pharmacy 28
- Family Members and Caregivers 1
- Health Care Executives and Administrators 219
Health Care Providers
- Nurses 43
- Pharmacists 12
- Physicians 96
Non-Health Care Professionals
- Educators 21
- Patients 8
Robert S. Wigton, MD; October 2003
Misplacement of an NG tube sends charcoal into the lung; the patient dies of complications.
- Spotlight Case
Charles Vincent, PhD; October 2003
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.
Christopher P. Landrigan, MD, MPH; October 2003
An infant sent to the ED for an LP is mistakenly redirected to the lab for a "blood test"; hours later, at a second ED, he is found to have meningitis.
Tejal K. Gandhi, MD, MPH; October 2003
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
Elizabeth A. Flynn, PhD, RPh; September 2003
Failure to shake a bottle leads to a toxic level of carbamazepine in a patient being treated for seizure disorder.
Verna C. Gibbs, MD; September 2003
A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy.
Linda D. Bradley, MD; September 2003
Following surgical team's makeshift assembly of equipment, a patient undergoing hysteroscopy suffers cardiac arrest on the OR table.
- 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.
Mark A. Crowther, MD, MSc; July 2003
Inadequate monitoring and management of warfarin places patient at significant risk of harm.
Marilynn M. Rosenthal, PhD; July 2003
An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.
Marilyn Sue Bogner, PhD; July 2003
Following hysterectomy, a PCA pump is mistakenly continued in a woman suffering an adverse reaction to morphine, noticed only when her respiratory status set off an alarm.
Ken J. Farion, MD; July 2003
A physician in the ED mistakenly glues a child's eye shut when attempting to close a facial wound with skin adhesive.
- Spotlight Case
Bernard Lo, MD; James A. Tulsky, MD; July 2003
A patient asks to be "DNR" because she misunderstood a vague discussion of resuscitation.
Hilary M. Babcock, MD; Victoria J. Fraser, MD; June 2003
Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections.
- Spotlight Case
James G. Adams, MD; June 2003
Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.
Lee A. Learman, MD, PhD; June 2003
A woman was told she miscarried, even though she was still pregnant.
Eran Kozer, MD; June 2003
A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.
Josh Gibson, MD; David H. Taylor, MD; June 2003
En route to x-ray, suicidal patient attempts to hang herself in washroom.
John E. Heffner, MD ; May 2003
A chest x-ray incorrectly read as pleural effusion, rather than lung collapse, leads to iatrogenic pneumothorax following thoracentesis.