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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: April 26, 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 (4)
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Displaying 1 - 4 of 4 WebM&M Case Studies
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    • The Forgotten Turn
    Susan Barbour, RN, MS, FNP| December 1, 2010
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    • 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.
    Recurrent Hypoglycemia: A Care Transition Failure?
    Ted Eytan, MD, MS, MPH| October 1, 2008
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    • An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.
    An Ounce of Prevention
    Nils Kucher, MD| January 1, 2006
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    • Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.
    Crossing the Line
    Jeremy P. Feldman, MD; Michael K. Gould, MD, MS | March 1, 2004
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    • A central line placed incorrectly causes a patient to suffer permanent neurologic damage.
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