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.

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This Month's WebM&Ms

Update Date: August 5, 2022

New

Challenges of Diabetes Management and Medication Reconciliation

Samson Lee, PharmD, and Mithu Molla, MD, MBA | August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to... Read More

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.

Submit Your Case

All WebM&M: Case Studies (7)

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1 - 7 of 7 WebM&M Case Studies

What Was in Those Platelets?

Roslyn Yomtovian, MD| July 1, 2008

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Following spinal surgeries, two different patients developed tachycardia, hypotension, and hypoxia due to sepsis. Given the similarity in clinical course, the hospital investigated and found that both patients had received platelets contaminated with Staphylococcus aureus.

Copy and Paste

William Hersh, MD| August 21, 2007

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A hospitalized elderly woman had clinical indications to receive medication to prevent venous thromboembolism. The intern noted this in the electronic record, and although this information was copied and pasted in the record on 4 consecutive days, the patient never received the intended prophylaxis and suffered a pulmonary embolism after discharge.

Back to Basics

Richard Hellman, MD| March 1, 2007

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For a woman with insulin-dependent diabetes mellitus, the admitting medical team ordered sliding scale insulin. Her blood glucose levels became very difficult to control, and she developed diabetic ketoacidosis. In the morning, the physician instituted a more appropriate insulin regimen.

An Ounce of Prevention

Nils Kucher, MD| January 1, 2006

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Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.

Hard to Swallow

Jeffrey Driver, JD, MBA | October 1, 2004

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Following a swallowing study, a speech pathologist recommends that a patient receive nothing by mouth, due to a high risk of aspiration. However, because the report is misfiled, no NPO order is implemented.

Did We Forget Something?

Verna C. Gibbs, MD| September 1, 2003

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A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy.

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.

WebM&M: Case Studies

This Month's WebM&Ms

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