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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 (5)
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Displaying 1 - 5 of 5 WebM&M Case Studies
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    • Reconciling Records
    Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH| November 1, 2010
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    • At two different hospitals, patients were instructed to continue home medications, even though their medication lists had errors that could have led to significant adverse consequences.
    Do Not Disturb!
    F. Daniel Duffy, MD; Christine K. Cassel, MD| October 1, 2007
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    • 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.
    Production Pressures
    Pascale Carayon, PhD| May 1, 2007
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    • On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected.
    Moving Pains
    Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD| July 1, 2006
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    • An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.
    40 of K
    Timothy S. Lesar, PharmD| November 1, 2003
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    • An unclear verbal order leads to administration of the wrong drug.
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