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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: May 16, 2022
Garima Agrawal, MD, MPH, and Mithu Molla, MD, MBA | May 16, 2022

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are... Read More

Alexandria DePew, MSN, RN, James Rice, & Julie Chou, BSN | May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an... 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 (2)

Published Date
PSNet Publication Date
1 - 2 of 2 WebM&M Case Studies
Allan S. Frankel, MD; Kathryn C. Adair, PhD; and J. Bryan Sexton, PhD| June 1, 2019
A proceduralist went to perform ultrasound and thoracentesis on an elderly man admitted to the medicine service with bilateral pleural effusions. Unfortunately, he scanned the wrong patient (the patient had the same last name and was in the room next door). When the patient care assistant notified the physician of the error, he proceeded to scan the correct patient. He later nominated the assistant for a Stand Up for Safety Award.
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Vimla L. Patel, PhD, and Timothy G. Buchman, PhD, MD| August 21, 2016
Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.