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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
This case describes the failure to identify a brewing abdominal process, which over the span of hours led to fulminant sepsis with... Read More
This case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from... Read More
A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency... Read More
This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis.... Read More
A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before... Read More
All WebM&M: Case Studies (2)
A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring. He eloped, then further complications resulted when law enforcement personnel were involved in his psychiatric emergency and when correctional mental health services were not available in a timely manner. The commentary discusses the importance of assessing for hypoxia-associated delirium and/or hippocampal damage/amnesia after any strangulation and the need for inpatient psychiatric hospitalization after emergency stabilization and management of delirium
