U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality
Provide Feedback |
Submit a Case
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: August 30, 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 (8)
Published Date
PSNet Publication Date
Continue Education
Additional Filters
Approach to Improving Safety
Clinical Area
Error Types
Safety Target
Setting of Care
Target Audience
Displaying 1 - 8 of 8 Results
  • 20
  • 50
  • 100
    • A Seasonal Care Transition Failure
    John Q. Young, MD, MPP| July 1, 2011
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.
    Treatment Challenges After Discharge
    Chase Coffey, MD, MS| November 1, 2010
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.
    Code Blue—Where To?
    Bruce D. Adams, MD| October 1, 2007
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient.
    Do Not Disturb!
    F. Daniel Duffy, MD; Christine K. Cassel, MD| October 1, 2007
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
    Right Patient, Wrong Sample
    Michael Astion, MD, PhD | December 1, 2006
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.
    Workaround Error
    Tess Pape, PhD, RN, CNOR| February 1, 2006
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
    Glucose Roller Coaster
    Bradley A. Sharpe, MD| July 1, 2004
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A woman hospitalized for CHF (with no history of diabetes) is given several rounds of insulin and D50, after repeated blood tests show her glucose to be dangerously high, then dangerously low. Turns out, the blood samples were drawn incorrectly and the signouts were incomplete.
    Waiting Too Long
    Mark A. Rosen, MD| November 1, 2003
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Due to the delay in anesthesiology becoming available for an urgent C-section, an infant is delivered with profound neurologic abnormalities.
    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