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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: October 31, 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 (7)
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Displaying 1 - 7 of 7 Results
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    • Wrong-Time Error With High-Alert Medication
    Annie Yang, PharmD, and Lewis Nelson, MD| September 1, 2016
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    • Admitted for knee surgery, a man was given his medications at 10 PM, including oral dofetilide (an antiarrhythmic agent with a strict 12-hour dosing interval). In the electronic health record, "q12 hour" drugs are scheduled for 6 AM and 6 PM by default. Because the patient was scheduled to leave for the operating room before 6 AM, the nurse gave the dose at 4 AM. Preoperative ECG revealed he had severe QTc prolongation (putting him at risk for a fatal arrhythmia), and surgery was canceled.
    Complaints as Safety Surveillance
    Jennifer Morris and Marie Bismark, MD| September 1, 2016
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    • Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.
    One Toxic Drug Is Not Like Another
    Eric S. Holmboe, MD| February 1, 2011
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    • A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.
    Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad
    Sumant Ranji, MD| April 1, 2008
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    • A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died.
    To Resuscitate or Not?
    Albert W. Wu, MD, MPH; Peter J. Pronovost, MD, PhD| January 1, 2004
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    • A patient receiving end-of-life care, whose code status was DNR, encounters a potentially life-threatening medication error.
    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.
    XL or Smaller?
    Eran Kozer, MD| June 1, 2003
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    • A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.
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