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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 31, 2022
Commentary by Jennifer Rosenthal, MD, MAS and Michelle Hamline, MD, PhD, MAS | August 31, 2022

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was... Read More

Spotlight Case
CE/MOC
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Anamaria Robles, MD, and Garth Utter, MD, MSc | August 31, 2022

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and... Read More

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Samantha Brown, MD, John S. Rose, MD, and David K. Barnes, MD | August 31, 2022

A 71-year-old man presented to a hospital-based orthopedic surgery clinic for a follow-up evaluation of his knee and complaints of pain and swelling in his right shoulder. His shoulder joint was found to be acutely inflamed and purulent fluid was... Read More

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 (5)

1 - 5 of 5 WebM&M Case Studies
Yi Lu, MD, PhD, and Douglas Salvador, MD, MPH| August 8, 2019
A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure. She was transferred to a neurosurgery service at an academic hospital when an MRI revealed a T6–T10 thoracic epidural abscess.
Reza Alaghehbandan, MD, MSc, and Stephen S. Raab, MD| March 1, 2013
A woman with abdominal pain, bloating, and weight loss went to her primary physician, who ordered imaging and a biopsy. Lymph node pathology was reported as Castleman disease. A specialist felt the presentation and test results were atypical for this diagnosis. Further testing revealed adult-onset celiac disease.
Jean L. Holley, MD | October 1, 2010
A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.
Saul N. Weingart, MD, PhD| August 1, 2006
In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.