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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: May 16, 2022
Garima Agrawal, MD, MPH, and Mithu Molla, MD, MBA | May 16, 2022

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are... Read More

Alexandria DePew, MSN, RN, James Rice, & Julie Chou, BSN | May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an... 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 (6)

1 - 6 of 6 WebM&M Case Studies
Thomas H. Gallagher, MD| May 1, 2011
Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.
Caprice C. Greenberg, MD, MPH| October 1, 2010
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.
Manish K. Sethi, MD| February 1, 2010
Over the course of 2 years, a patient who frequently came to the emergency department complaining of abdominal pain underwent 12 CT scans of the abdomen and pelvis. All of them were completely normal.
Christopher Fee, MD| March 21, 2009
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.
Arpana Vidyarthi, MD| March 1, 2004
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.