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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: August 5, 2022
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.

All WebM&M: Case Studies (3)

1 - 3 of 3 WebM&M Case Studies
Brian F. Olkowski, DPT; Mary Ravenel, MSN; and Michael F. Stiefel, MD, PhD| April 1, 2018
Following elective lumbar drain placement to treat hydrocephalus and elevated intracranial pressures, a woman was admitted to the ICU for monitoring. After the patient participated in prescribed physical therapy on day 5, she complained of headaches, decreased appetite, and worsening visual problems—similar to her symptoms on admission. The nurse attributed the complaints to depression and took no action. Early in the morning, the patient was found barely arousable. The lumbar drain had dislodged, and a CT scan revealed the return of extensive hydrocephalus.
Jeffrey H. Barsuk, MD, MS| July 1, 2012
Following gallbladder removal, a patient presented with abdominal pain and fluid in her abdomen. The admitting team, comprised of a second-year resident and intern, decided to perform a paracentesis (fluid removal) without supervision. The patient had a complication necessitating emergency surgery and an ICU stay.
Colin P. West, MD, PhD| January 1, 2008
An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated.