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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 (5)

1 - 5 of 5 WebM&M Case Studies
Carlton R. Moore, MD, MS| August 1, 2012
Drawn on a Thursday, basic labs for a 10-year-old girl came back over the weekend showing a high glucose level, but neither the covering physician nor the primary pediatrician saw the results until the patient's mother called on Monday. Upon return to the clinic for follow-up, the child's glucose level was dangerously high and urinalysis showed early signs of diabetic ketoacidosis.
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.
Elisa W. Ashton, PharmD| February 1, 2012
After entering an electronic prescription for the wrong patient, the clinic nurse deleted it, assuming that would cancel the order at the pharmacy. However, the prescription went through to the pharmacy, and the patient received it.
Ronald L. Arenson, MD| March 1, 2006
A patient with metastatic cancer admitted for pain control develops acute shortness of breath. The overnight resident reads the CT as a large pulmonary embolism, but the next morning, the attending reads it differently.
Charles Vincent, PhD| October 1, 2003
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.