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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: February 1, 2023
Craig Keenan, MD, Scott MacDonald, MD, Ashley Takeshita, and Dale Sapell, PharmD | February 1, 2023

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... Read More

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Elizabeth Partridge, MD, MPH, Daniel Dodson, MD, MS, Mary Reilly, MHA, BSN, RN, CIC and Stuart H. Cohen, MD | February 1, 2023

A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems,... Read More

Dahlia Zuidema, PharmD, Berit Bagley, MSN, and Charity L Tan MSN | February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication... Read More

Nicole A. Weiss, MD | February 1, 2023

A 27-year-old pregnant woman was diagnosed with severe pulmonary arterial hypertension at 29 weeks estimated gestational age (EGA) and admitted for elective cesarean delivery with lumbar epidural anesthesia at 36 weeks EGA. After epidural catheter... 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 (2)

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Displaying 1 - 2 of 2 WebM&M Case Studies
Giovanni Elia, MD; Susan Barbour, RN, MS; and Wendy G. Anderson, MD, MS| August 1, 2018
Hospitalized in the ICU after cardiac arrest and loss of cardiac function for 15 minutes, an older man experienced worsening neurological status. After extensive discussions about goals of care, the family agreed to a DNR order. Over the next week, his condition declined, and the family decided to transition to comfort measures. Orders were written but shortly thereafter, the family spoke with the ICU resident and reversed their decision. The resident canceled the terminal extubation orders without communicating the order change to other team members. Another nurse found the canceled orders, thought it was an error, and asked another physician (who was also unaware of the change in plans) to reinstate the orders. The patient was extubated and died a few hours later.
Joseph G. Ouslander, MD, and Alice Bonner, PhD, GNP| December 1, 2013
Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.