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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 (5)

Displaying 1 - 5 of 5 WebM&M Case Studies
Katrina Pasao, MD and Pouria Kashkouli, MD, MS | March 31, 2022

This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments. Over the course of the following year, the patient’s son and daughter were contacted at various points to re-establish care, but he continued to miss scheduled appointments and treatments. During a hospital admission, a palliative care team determined that the patient did not have capacity to make complex medical decisions. He was discharged to a skilled nursing facility, and then to a board and care when he failed to improve. He missed two more oncology appointments before being admitted with cancer-related pain. Based on the patient’s poor functional status, he was not considered a candidate for additional therapy. After a discussion of goals of care with the patient and daughter, he was enrolled in hospice. The commentary outlines key elements for assessing patient capacity, the importance of understanding the patient’s psychosocial history, and strategies to strengthen psychosocial training for medical and nursing trainees.

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Urmimala Sarkar, MD, MPH| October 1, 2013
Although the mother of a child, born male who identified as and expressed externally as a girl, had alerted the clinic of the child's preferred name when making the appointment, the medical staff called for the patient in the waiting room using her legal (masculine) name.
Neil A. Holtzman, MD, MPH| December 1, 2004
A pregnant woman is offered genetic testing for herself and her husband. Although he declines, the next time he undergoes routine testing, the phlebotomist overrides the consent in the computerized record and runs the test anyway.
Allan Krumholz, MD| December 1, 2004
At a new patient visit, a man with seizure disorder requests a 'handicapped' license plate due to difficulty walking long distances. To his surprise, the physician explains that he needs to report his seizures to the DMV.