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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
A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac... Read More
A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia.... Read More
An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing... Read More
This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy... Read More
All WebM&M: Case Studies (2)
A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone. The patient subsequently developed severe metabolic encephalopathy due to overdose of both gabapentin and opiates and failure to reduce medication doses in the setting of ESRD. The commentary discusses pain management and the signs of gabapentin toxicity in patients with renal dysfunction, as well the implications of clinical decision support-related alert fatigue and approaches to reduce adverse events arising from drug-disease interactions.
