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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: April 26, 2023
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 (8)
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Displaying 1 - 8 of 8 WebM&M Case Studies
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    • Isolated Clot, Real Error
    Anna Parks, MD, and Margaret C. Fang, MD, MPH | March 1, 2018
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    • One day after reading only the first line of a final ultrasound result (which stated that the patient had a thrombosis), an intern reported to the ICU team that the patient had a DVT. Because she had postoperative bleeding, the team elected to place an inferior vena cava (IVC) filter rather than administer anticoagulants to prevent a pulmonary embolism (PE). The next week, a new ICU team discussed the care plan and questioned the IVC filter. The senior resident reviewed the radiology records and found the ultrasound report actually stated the thrombosis was in a superficial vein with low risk for PE, which meant that the correct step in management of this patient's thrombosis should have been surveillance.
    Near Miss with Bedside Medications
    Albert Wu, MD, MPH| November 1, 2011
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    • An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.
    Watch the Warfarin!
    Margaret Fang, MD, MPH; Raman Khanna, MD, MAS| July 1, 2011
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    • Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high.
    Recurrent Hypoglycemia: A Care Transition Failure?
    Ted Eytan, MD, MS, MPH| October 1, 2008
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    • An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.
    Do Not Disturb!
    F. Daniel Duffy, MD; Christine K. Cassel, MD| October 1, 2007
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    • Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
    Medication Reconciliation: Whose Job Is It?
    Eric G. Poon, MD, MPH| September 1, 2007
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    • Hospitalized for surgery, a woman with a history of seizures was given an overdose of the wrong medicine due to multiple errors, including an inaccurate preadmission medication list, failure to verify medication history, and uncoordinated information systems.
    Moving Pains
    Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD| July 1, 2006
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    • An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.
    Discharge Fumbles
    Alan Forster, MD, MSc| December 1, 2004
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    • A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge.
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