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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 (5)
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    • Staggered Sensitivity Results
    B. Joseph Guglielmo, PharmD| March 1, 2007
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    • Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.
    Right? Left? Neither!
    Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH| May 1, 2006
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    • A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
    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.
    Around the Block
    Tracy Minichiello, MD| March 1, 2005
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    • Despite a box on the admission form warning against using blood thinners and epidural anesthesia together, a patient admitted for elective surgery receives both, and becomes permanently paralyzed.
    Too Tight Control
    Haya R. Rubin, MD, PhD; Vera T. Fajtova, MD| May 1, 2004
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    • To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic.
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