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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 16, 2022
Nasim Hedayati, MD, and Richard White, MD | November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two... Read More

Leilani Schweitzer | November 16, 2022

A 58-year-old man underwent a complex surgery to replace his aortic value. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed ... 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)

Displaying 1 - 6 of 6 WebM&M Case Studies
Clinton J. Coil, MD, MPH, and Mallory D. Witt, MD| September 1, 2017
A woman developed sudden nausea and abdominal distension after undergoing inferior mesenteric artery stenting. The overnight intern forgot to follow up on her abdominal radiograph, which resulted in a critical delay in diagnosing acute mesenteric artery dissection and bowel infarction.
F. Daniel Duffy, MD; Christine K. Cassel, MD| October 1, 2007
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
Catherine McLean, MD| March 1, 2005
At a routine clinic visit, screening labs are sent for a man with HIV. Not notified of the results, he assumes they are normal. One month later, he develops a classic syphilitic rash.
Bradley A. Sharpe, MD| July 1, 2004
A woman hospitalized for CHF (with no history of diabetes) is given several rounds of insulin and D50, after repeated blood tests show her glucose to be dangerously high, then dangerously low. Turns out, the blood samples were drawn incorrectly and the signouts were incomplete.
Arpana Vidyarthi, MD| March 1, 2004
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.