U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality
Provide Feedback |
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: 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 (2)
Published Date
PSNet Publication Date
Continue Education
Additional Filters
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Displaying 1 - 2 of 2 WebM&M Case Studies
  • 20
  • 50
  • 100
    • Danger in Disruption
    Dorrie K. Fontaine, RN, PhD| October 1, 2009
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A toddler admitted for severe dehydration requires a femoral IV. The anesthesiologist ignores a nurse's reminder that hospital policy requires monitoring if a child is to receive sedation in the unit. When the nurse attempts to stop the procedure, the anesthesiologist throws the needle to the floor.
    On the Other Hand
    Elizabeth A. Henneman, RN, PhD| May 1, 2007
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.
    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