U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality
Provide Feedback |
Submit a Case
Patient Safety Network
Search Tips

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 (3)
Published Date
PSNet Publication Date
Continue Education
Additional Filters
Approach to Improving Safety
Clinical Area
Error Types
Safety Target
Setting of Care
Target Audience
Displaying 1 - 3 of 3 Results
  • 20
  • 50
  • 100
    • Hyperbilirubinemia Refractory to Phototherapy
    Vinod K. Bhutani, MD, and Ronald J. Wong| October 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A newborn with elevated total serum bilirubin (TSB) due to hemolytic disease was placed on a mattress with embedded phototherapy lights for treatment, but the TSB continued to climb. The patient was transferred to the neonatal ICU for an exchange transfusion. The neonatologist requested testing of the phototherapy lights, and their irradiance level was found to be well below the recommended level. The lights were replaced, the patient's TSB level began to drop, and the exchange transfusion was aborted.
    High-Risk Medications, High-Risk Transfers
    Nancy Staggers, PhD, RN| October 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.
    Impatient Inpatient Dosing
    Richard H. White, MD | August 21, 2005
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding.
    Back To Top
    Terms and Conditions | Privacy Policy | External Link Disclaimer | RSS Feed

    Connect With Us

    Facebook Twitter You Tube LinkedIn

    Sign up for Email Updates

    Agency for Healthcare Research and Quality

    5600 Fishers Lane
    Rockville, MD 20857
    Telephone: (301) 427-1364

    Submit Your Innovations