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 involves a procedural sedation error in a 3-year-old patient who presented to the... Read More
This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors... Read More
This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical... Read More
All WebM&M: Case Studies (5)
This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors for falls should be considered in care planning and approaches to fall prevention in long-term care settings.
A 3-month-old male infant, born at 26 weeks’ gestation with a history of bowel resection and anastomosis due to necrotizing enterocolitis, was readmitted for abdominal distension and constipation. He was transferred to the pediatric intensive care unit (PICU) for management of severe sepsis and an urgent exploratory laparotomy was scheduled for suspected obstruction. The PICU team determined that the patient was stable for brief transport from the PICU to the operating room (OR). During intrahospital transport, the patient had two bradycardic episodes – the first self-resolved but the second necessitated chest compressions and intubation. The patient was rapidly moved to the OR where return of spontaneous circulation occurred within five minutes. The associated commentary describes the risks associated with intrahospital transport (particularly among pediatric patients) and critical processes that should be put in place to mitigate these risks via clear communication and structured decision-making among the intrahospital transport team.