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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 (8)
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    • Defensive Medicine: "Glowing" with Pain
    Manish K. Sethi, MD| February 1, 2010
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    • 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.
    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.
    The Wrongful Resuscitation
    Joan M. Teno, MD, MS| April 1, 2008
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    • Despite having a signed DNR (do not resuscitate) form, an elderly man brought to the emergency department with severe pain was rushed to the operating room for urgent abdominal aortic aneurysm repair.
    Abnormal Volunteer Results
    Conrad V. Fernandez, MD| June 1, 2007
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    • A healthy woman who volunteered to participate in a radiology study was notified several weeks later of a "major abnormality" discovered on her MRI. She sought further evaluation and was diagnosed with uterine cancer.
    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.
    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.
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