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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: October 31, 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 Results
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    • Consequences of Medical Overuse
    Daniel J. Morgan, MD, MS, and Andrew Foy, MD| March 1, 2017
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    • Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.
    On the Other Hand
    Elizabeth A. Henneman, RN, PhD| May 1, 2007
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    • A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.
    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.
    A "Weak" Response
    Anna B. Reisman, MD| December 1, 2004
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    • Feeling "weak" late at night, a patient calls his doctor's office. The covering physician misses a few clues, which might have prompted a different plan.
    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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