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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 (3)
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Displaying 1 - 3 of 3 WebM&M Case Studies
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    • Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention
    Scott D. Nelson, PharmD, MS| March 1, 2017
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    • Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.
    Antiseizure Medication Disorder
    Brian K. Alldredge, PharmD| May 1, 2007
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    • An elderly patient with a seizure disorder (and recent admission for uncontrolled seizures) was admitted to the hospital to evaluate symptoms of lethargy, confusion, and decreased appetite. The team misattributed his mental status change to an infection but later discovered that the patient had phenytoin toxicity.
    Inappropriate Antibiotic Use
    Hilary M. Babcock, MD; Victoria J. Fraser, MD| June 1, 2003
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    • Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections.
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