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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
This case describes the failure to identify a brewing abdominal process, which over the span of hours led to fulminant sepsis with... Read More
This case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from... Read More
A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency... Read More
This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis.... Read More
A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before... Read More
All WebM&M: Case Studies (6)
The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause serious adverse drug events. The commentary summarizes risk factors for medication discrepancies and approaches for safer medication administration, including the use of teach-back counseling, pharmacy-led medication reconciliation during transitions of care, and electronic health record-based strategies for safer prescribing.
