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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 (7)
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Displaying 1 - 7 of 7 WebM&M Case Studies
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    • If You Say So: Taking a Syringe at Face Value in the Operating Room
    Audrey Lyndon, PhD, RN, and Stephanie Lim, MD| June 1, 2019
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    • During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.
    It's Sarah, Not Stephen!
    Urmimala Sarkar, MD, MPH| October 1, 2013
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    • Although the mother of a child, born male who identified as and expressed externally as a girl, had alerted the clinic of the child's preferred name when making the appointment, the medical staff called for the patient in the waiting room using her legal (masculine) name.
    The ECG Is Not Normal
    Abigail Zuger, MD| June 1, 2011
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    • An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.
    EMR Entry Error: Not So Benign
    Ross Koppel, PhD| April 1, 2009
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    • A patient hospitalized with Pneumocystis jiroveci pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.
    OR Peeping
    Colin F. Mackenzie, MD| March 1, 2004
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    • Video monitors near the operating room reveal a patient's identity, and gossip spreads about a very private issue.
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