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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: April 26, 2023
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 (7)
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Displaying 1 - 7 of 7 WebM&M Case Studies
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    • A Pill Organizing Plight
    Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD| September 1, 2016
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    • An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.
    Over Not So Easy
    Russ Cucina, MD, MS| July 1, 2006
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    • Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.
    Language Barrier
    Glenn Flores, MD| April 1, 2006
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    • With no one to interpret for them and pharmacy instructions printed only in English, non–English-speaking parents give their child a 12.5-fold overdose of a medication.
    Poor Prognosis
    Elizabeth B. Lamont, MD, MS| September 1, 2004
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    • Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.
    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.
    Lethal Cap
    Dean Schillinger, MD| March 1, 2004
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    • A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
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