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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 (12)
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Displaying 1 - 12 of 12 Results
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    • "Recurrent" Appendicitis
    Caprice C. Greenberg, MD, MPH| October 1, 2010
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    • Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.
    All in the History
    Christopher Fee, MD| March 21, 2009
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    • Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
    Code Blue—Where To?
    Bruce D. Adams, MD| October 1, 2007
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    • A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient.
    Collegiality vs. Competence
    Todd Sagin, MD, JD| March 1, 2006
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    • Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
    Carpe Diem (Seize the Day)
    Allan Krumholz, MD| December 1, 2004
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    • At a new patient visit, a man with seizure disorder requests a 'handicapped' license plate due to difficulty walking long distances. To his surprise, the physician explains that he needs to report his seizures to the DMV.
    Security Lapse
    Daniel Mason, MD| September 1, 2004
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    • A medical student discovers that a hospital's radiology records are accessible via Internet, without any security, and struggles with whether and to whom to report the obvious HIPAA violation.
    Listen to the Family
    Darrell Campbell, Jr., MD| June 1, 2004
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    • Despite persuasion from a surgical resident that her mother's life was in danger, a patient's daughter refuses consent for surgery on her mother. This was wise, since the procedure was intended for a different patient with the same unusual surname.
    No Blood, Please
    Bryan A. Liang, MD, PhD, JD| May 1, 2004
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    • Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
    Privacy Gone Awry
    Stephen G. Pauker, MD; Susan P. Pauker, MD| May 1, 2004
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    • Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.
    OR Peeping
    Colin F. Mackenzie, MD| March 1, 2004
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    • Video monitors near the operating room reveal a patient's identity, and gossip spreads about a very private issue.
    Feeling No Pain
    Marilyn Sue Bogner, PhD| July 1, 2003
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    • Following hysterectomy, a PCA pump is mistakenly continued in a woman suffering an adverse reaction to morphine, noticed only when her respiratory status set off an alarm.
    Another Fall
    Sidney T. Bogardus, Jr., MD| April 1, 2003
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    • Delirious and coagulopathic patient with subdural hematomas falls out of bed—twice!
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