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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: August 5, 2022
New
Challenges of Diabetes Management and Medication Reconciliation
Samson Lee, PharmD, and Mithu Molla, MD, MBA | August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to... 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 (4)
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1 - 4 of 4 WebM&M Case Studies
Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.
Cynthia Li, PharmD, and Katrina Marquez, PharmD| July 28, 2021
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    • This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

    Dangerous Dialysis
    Jean L. Holley, MD | October 1, 2010
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    • A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.
    Bad Writing, Wrong Medication
    Beth Devine, PharmD, MBA, PhD| April 1, 2010
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    • A medication dispensing error causes nausea, sweating, and irregular heartbeat in an elderly man with a history of cardiac arrhythmia. Investigation reveals that the patient was given thyroid replacement medication instead of antiarrhythmic medication.
    It's All in the Syringe
    Saul N. Weingart, MD, PhD| August 1, 2006
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    • In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.
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