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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: August 5, 2022
Samson Lee, PharmD, and Mithu Molla, MD, MBA | August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to... Read More

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)

1 - 8 of 8 WebM&M Case Studies
Richard Rothman, MD, PhD; Sahael Stapleton, MD| May 1, 2011
An emergency department worker develops chicken pox following an exposure during one of his shifts.
Eric S. Holmboe, MD| February 1, 2011
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.
Susan Barbour, RN, MS, FNP| December 1, 2010
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.
Manish K. Sethi, MD| February 1, 2010
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.
James A. Yates, MD| March 1, 2006
A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
Todd Sagin, MD, JD| March 1, 2006
Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
Bryan A. Liang, MD, PhD, JD| May 1, 2004
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.