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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 (6)

1 - 6 of 6 WebM&M Case Studies
Russ Cucina, MD, MS| July 1, 2006
Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.
Glenn Flores, MD| April 1, 2006
With no one to interpret for them and pharmacy instructions printed only in English, non–English-speaking parents give their child a 12.5-fold overdose of a medication.
James E. Heubi, MD | January 1, 2006
Parents of a 5-year-old, told to give their son acetaminophen for his fever, return 2 days later because he is acutely ill. Tests reveal dangerously high acetaminophen levels. It turns out the parents had miscalculated the dosage.
Elizabeth B. Lamont, MD, MS| September 1, 2004
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.
Bryan A. Liang, MD, PhD, JD| May 1, 2004
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
Dean Schillinger, MD| March 1, 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.