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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 (6)
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Displaying 1 - 6 of 6 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.
    Round-Trip Service
    Mary H. McGrath, MD, MPH| December 1, 2009
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    • Eager to have his knee replaced, an active older patient travels overseas for the surgery. At home 2 weeks later, he develops acute pain and swelling in his knee. A local orthopedic surgeon's office tells him to contact his operating physician, nearly 5000 miles away.
    Difficult Encounters: A CMO and CNO Respond
    Ernest J. Ring, MD; Jane E. Hirsch, RN, MS| October 1, 2009
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    • Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene.
    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.
    Liposuction Gone Awry
    James A. Yates, MD| March 1, 2006
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    • A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
    Fumbled Handoff
    Arpana Vidyarthi, MD| March 1, 2004
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    • 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.
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