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
Atul K. Madan, MD ; May 2003
A blood-soaked BP cuff used on one trauma patient is re-used on the next trauma patient, with no regard to universal precautions.
Vanessa M. Givens, MD; Gary H. Lipscomb, MD; May 2003
A woman is given methotrexate prematurely for suspected ectopic pregnancy and ultimately has salpingectomy.
- Spotlight Case
Adrienne G. Randolph, MD, MSc ; May 2003
An infant codes due to pulmonary emboli after a central line flush.
Robert I. Simon, MD; May 2003
Suicidal patient who admits having firearm refuses to remove gun from home for nearly 3 months.
- Spotlight Case
Sidney T. Bogardus, Jr., MD; April 2003
Delirious and coagulopathic patient with subdural hematomas falls out of bedtwice!
Andre R. Campbell, MD; April 2003
Laparoscopic colostomy completed in reverse induces total bowel obstruction.
Jackie Thomas, MD; Mary Hannah, MD; April 2003
Incorrect dating criteria in a woman late entering prenatal care nearly leads to induction of a pre-term infant.
Rainu Kaushal, MD, MPH; April 2003
A boy received an overdose of phenytoin due to ambiguous use of abbreviations.
Michael Cohen, RPh, MS, ScD (hon); April 2003
Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.
Kaveh G. Shojania, MD; February 2003
A man almost received a medication intended for another patient with the same last name in the same room.
- Spotlight Case
Paul Barach, MD, MPH; February 2003
A boy undergoing knee surgery stopped breathing after inadvertently being given a paralytic medication instead of an antibiotic.
Verna C. Gibbs, MD; Lucian L. Leape, MD ; February 2003
A woman required emergency vascular surgery due to a complication during routine laparoscopic tubal ligation.
John Gosbee, MD, MS; Laura Lin Gosbee, MASc; February 2003
An infusion pump being used for routine sedation in a child undergoing a magnetic resonance imaging (MRI) scan flew across the room and hit the MRI magnet, narrowly missing the child.
Richard J. Goldberg, MD, MS; February 2003
An elderly man with delusions and progressive neurological symptoms initially attributed to psychosis is found to have metastatic cancer.