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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 16, 2022
Nasim Hedayati, MD, and Richard White, MD | November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two... Read More

Leilani Schweitzer | November 16, 2022

A 58-year-old man underwent a complex surgery to replace his aortic valve. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed ... 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 (4)

Displaying 1 - 4 of 4 WebM&M Case Studies
Zara Cooper, MD, MSc| September 25, 2019
A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear. A second CT scan showed a 6 cm abscess near the liver, likely arising from a perforated gallbladder. The patient underwent an urgent open cholecystectomy and drainage of the abscess.
Mitch Rodriguez, MD, MBA; Rebecca Mannel, BS, IBCLC; Donna Frye, RN, MN| September 1, 2008
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
Joseph M. Furman, MD, PhD| June 1, 2004
A woman presents to the ED with severe vertigo and vomiting. Over several hours, she is handed off to three different physicians, none of whom suspects a dangerous lesion. Later, an hour after onset of a severe headache, she dies.