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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
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)

1 - 4 of 4 WebM&M Case Studies
Kevin Moore, MBBS, PhD| December 1, 2015
A man with cirrhosis and abdominal distension was found to have significant ascites. The emergency department providers performed a large volume paracentesis to relieve his symptoms, but, as the 10th liter of fluid was removed, the patient became acutely hypotensive.
Frank I. Scott, MD, MSCE, and Gary R. Lichtenstein, MD| June 1, 2015
Admitted to the hospital with a small bowel obstruction and ileitis consistent with an exacerbation of Crohn disease, a man was given empiric antibiotic therapy and infliximab prior to consultation with gastroenterology. Gastroenterology recommended sending stool studies and initiating infliximab only after those studies were negative for infection. The stool studies were sent, but the primary team did not discontinue the infliximab. The patient was found to have Clostridium difficile infection.
Ronald L. Arenson, MD| March 1, 2006
A patient with metastatic cancer admitted for pain control develops acute shortness of breath. The overnight resident reads the CT as a large pulmonary embolism, but the next morning, the attending reads it differently.