U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality
Provide Feedback |
Submit a Case
Patient Safety Network
Search Tips

WebM&M: Case Studies

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.

Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

This Month's WebM&Ms

Update Date: October 31, 2023
Have you encountered medical errors or patient safety issues?
Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

All WebM&M: Case Studies (8)
Published Date
PSNet Publication Date
Continue Education
Additional Filters
Approach to Improving Safety
Clinical Area
Error Types
Safety Target
Setting of Care
Target Audience
Displaying 1 - 8 of 8 Results
  • 20
  • 50
  • 100
    • Outbreak
    Richard Rothman, MD, PhD; Sahael Stapleton, MD| May 1, 2011
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • An emergency department worker develops chicken pox following an exposure during one of his shifts.
    One Toxic Drug Is Not Like Another
    Eric S. Holmboe, MD| February 1, 2011
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.
    The Forgotten Turn
    Susan Barbour, RN, MS, FNP| December 1, 2010
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Admitted to the hospital with right-hip and left-arm fractures, an elderly woman remained on the same bed from the emergency department for nearly 16 hours and developed a moderate-sized, stage 2 pressure ulcer.
    Defensive Medicine: "Glowing" with Pain
    Manish K. Sethi, MD| February 1, 2010
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Over the course of 2 years, a patient who frequently came to the emergency department complaining of abdominal pain underwent 12 CT scans of the abdomen and pelvis. All of them were completely normal.
    Collegiality vs. Competence
    Todd Sagin, MD, JD| March 1, 2006
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
    Liposuction Gone Awry
    James A. Yates, MD| March 1, 2006
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
    No Blood, Please
    Bryan A. Liang, MD, PhD, JD| May 1, 2004
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
    Back To Top
    Terms and Conditions | Privacy Policy | External Link Disclaimer | RSS Feed

    Connect With Us

    Facebook Twitter You Tube LinkedIn

    Sign up for Email Updates

    Agency for Healthcare Research and Quality

    5600 Fishers Lane
    Rockville, MD 20857
    Telephone: (301) 427-1364

    Submit Your Innovations