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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 (5)

Displaying 1 - 5 of 5 WebM&M Case Studies
Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP| May 27, 2020
A patient with multiple comorbidities and chronic pain was admitted for elective spinal decompression and fusion. The patient was placed on a postoperative patient-controlled analgesia (PCA) for pain control and was later found unresponsive. The case illustrates risks associated with opioid administration through PCA, particularly among patients at high risk for postoperative opioid-induced respiratory depression.
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Amy A. Vogelsmeier, PhD, RN| September 1, 2011
Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.
Susan Barbour, RN, MS, FNP| December 1, 2010
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.
Douglas D. Brunette, MD| March 1, 2005
The challenges of examining and imaging a hospitalized morbidly obese patient delay diagnosis, threatening the patient's life.