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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: November 30, 2023
New
Medication Mix-Up Leads to Patient Death.
Luciano Sanchez, PharmD and Patrick Romano, MD, MPH | November 30, 2023

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

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 (7)
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Displaying 1 - 7 of 7 Results
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    • Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.
    Cynthia Li, PharmD, and Katrina Marquez, PharmD| July 28, 2021
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    • This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

    New Patient Mistakenly Checked in as Another
    Robert A. Green, MD, MPH, and Jason Adelman, MD, MS| January 1, 2016
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    • Presenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email.
    The ECG Is Not Normal
    Abigail Zuger, MD| June 1, 2011
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    • An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.
    Right? Left? Neither!
    Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH| May 1, 2006
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    • A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
    Overriding Considerations
    Neil A. Holtzman, MD, MPH| December 1, 2004
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    • 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.
    Allergy to Holter
    Mark V. Williams, MD| July 1, 2004
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    • A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead.
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