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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 (4)

1 - 4 of 4 WebM&M Case Studies
Luciano Sanchez, PharmD, Hollie Porras, PharmD, BCPS, and Cathy Lammers, MD | July 8, 2022

This WebM&M highlights two cases of patient safety events that occurred due to medication dosing related to diagnostic imaging. The commentary highlights the challenges of administering sedation for diagnostic imaging, the use of risk stratification to understand patient risk for oversedation, and strategies for appropriate monitoring and communication.

Emanuel Kanal, MD| May 1, 2019
After presenting with new left-sided weakness and hypertensive urgency, a woman was admitted to the stroke unit, and the consulting neurologist ordered an urgent MRI of the brain. Although the patient required pushes of intravenous hypertensive medication to control her blood pressure (BP), she was taken to radiology where the nurse checked her BP one more time before leaving her in the MRI machine with the BP cuff still on. Within a few seconds of starting the scan, the patient's arm with the BP cuff was sucked into the MRI scanner, making a loud noise.
An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.
John Gosbee, MD, MS; Laura Lin Gosbee, MASc| February 1, 2003
An infusion pump being used for routine sedation in a child undergoing a magnetic resonance imaging (MRI) scan flew across the room and hit the MRI magnet, narrowly missing the child.