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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: October 30, 2024
Spotlight Case
CE/MOC
New
Garth Utter, MD | October 30, 2024
A 38-year-old man sustained multiple injuries in a motorcycle crash, including head trauma, chest injuries, and spinal... Read More
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Spotlight Case
CE/MOC
New
Ryan Martin, MD, FCNS and Kiarash Shahlaie, MD, PhD, FAANS, FCNS | October 30, 2024
A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury. A head CT scan was read as... Read More
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Victoria Jackson, DNP, RN, PHN, FNP-C, PA-C and Anna Satake, PhD, MSN, GCNS, RN | October 30, 2024
These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous... 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 (662)
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Displaying 541 - 560 of 662 Results
Displaying 541 - 560 of 662 Results
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Glenn Flores, MD|
April 1, 2006
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With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Charles L. Bosk, PhD|
April 1, 2006
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Because members of the OR team were reluctant to speak up to a senior surgeon with a reputation for yelling, a child undergoing surgery experiences a complication and has a delay in chemotherapy.
Ronald L. Arenson, MD|
March 1, 2006
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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.
Todd Sagin, MD, JD|
March 1, 2006
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Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
James A. Yates, MD|
March 1, 2006
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A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
Tess Pape, PhD, RN, CNOR|
February 1, 2006
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Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
Mary K. Goldstein, MD, MS |
February 1, 2006
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Failure to enter documentation of a DNR order causes a severely ill elderly man to be resuscitated against his wishes. Shortly thereafter, the patient's wife confirms his wishes, and within minutes, the patient dies.
Christopher Beach, MD|
February 1, 2006
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A woman comes to the ED with mental status changes. Although numerous tests are run and she is admitted, a critical test result fails to reach the medicine team in time to save the patient's life.
James E. Heubi, MD |
January 1, 2006
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Parents of a 5-year-old, told to give their son acetaminophen for his fever, return 2 days later because he is acutely ill. Tests reveal dangerously high acetaminophen levels. It turns out the parents had miscalculated the dosage.
Lee Berkowitz, MD|
January 1, 2006
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Over several weeks, a man with left foot pain and numbness is evaluated by numerous doctors, each resident and attending pair offering a different incorrect diagnosis until the patient's fourth visit.
Nils Kucher, MD|
January 1, 2006
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Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.
Louis P. Halamek, MD |
December 1, 2005
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A resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor.
Lisa I. Iezzoni, MD, MSc|
December 1, 2005
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A man is discharged home with injections and written instructions on how to administer his medications. However, the nurse and pharmacist did not notice that he was blind.
Robert M. Wachter, MD |
December 1, 2005
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A medical student notices that, prior to surgery, a urinary catheter is inserted into a child without sterile prep. Being new to the OR setting, he says nothing until a few days later on rounds when the patient shows signs of infection.
Lawrence Smith, MD|
November 1, 2005
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Told to give a patient one gram of steroids, an intern mistakenly orders fifty 20-mg pills. Although a pharmacist questions the order, the intern insists that the medication be given as ordered.
Mary E. Foley MS, RN |
November 1, 2005
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An ICU patient scheduled for a CT scan is given contrast solution by a nurse unfamiliar with its administration. Rather than orally, the contrast is mixed into a bag of saline and given intravenously.
Frank Federico, RPh |
November 1, 2005
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An elderly man on warfarin is admitted to the hospital with suspected meningitis. The admitting team bases his dose of warfarin on the paramedics' run-sheet but does not verify the dose. The patient winds up with a dangerous INR level, which causes a serious neurologic complication.
Jeffrey M. Taekman, MD; Melanie C. Wright, PhD |
September 1, 2005
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A few minutes after the code is "called" on an elderly patient, a nurse rushes from the room stating that the patient is breathing spontaneously.
John Gosbee, MD, MS |
September 1, 2005
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In labor, a woman receiving medications for preeclampsia, labor induction, and hydration from a multi-channel infusion pump is mistakenly given an extra bolus of the wrong drug.
Jerry H. Gurwitz, MD|
September 1, 2005
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An elderly man with diabetes admitted to the hospital with hypoglycemia is switched from a combination medication (two pills in one) to a single drug. Two weeks later, he presents with mental status changes.
