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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: November 30, 2023
New
Medication Mix-Up Leads to Patient Death.
Luciano Sanchez, PharmD and Patrick Romano, MD, MPH | November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing... 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 (3)
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    • Where's the Feeding Tube?
    Norma A. Metheny, RN, PhD; Kathleen L. Meert, MD| September 1, 2008
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    • A boy was receiving enteral feedings while recovering from a traumatic brain injury. The nasojejunal tube migrated to the gastric area, and the patient developed pneumonia, likely due to aspiration.
    On the Other Hand
    Elizabeth A. Henneman, RN, PhD| May 1, 2007
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    • A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.
    Hidden Mystery
    Douglas D. Brunette, MD| March 1, 2005
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    • The challenges of examining and imaging a hospitalized morbidly obese patient delay diagnosis, threatening the patient's life.
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