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.

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This Month's WebM&Ms

Update Date: April 26, 2023

Spotlight Case

CE/MOC

The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.

Commentary by Michael Leonardo Amashta, MD, and David K. Barnes, MD, FACEP | April 26, 2023

This case involves a procedural sedation error in a 3-year-old patient who presented to the... Read More

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Spotlight Case

CE/MOC

Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.

Barbara Resnick, PhD, CRNP, and Marie Boltz, PhD, CRNP | April 26, 2023

This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors... Read More

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The Danger of 10% Intravenous Calcium Chloride Extravasation.

Charleen Singh, PhD, MSN/ED, FNP-BC, CWOCN, RN and Brent Luu, PharmD, BCACP | April 26, 2023

This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical... 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.

Submit Your Case

All WebM&M: Case Studies (603)

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Displaying 581 - 600 of 603 WebM&M Case Studies

Feeling No Pain

Marilyn Sue Bogner, PhD| July 1, 2003

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Following hysterectomy, a PCA pump is mistakenly continued in a woman suffering an adverse reaction to morphine, noticed only when her respiratory status set off an alarm.

Check the Wristband

Marilynn M. Rosenthal, PhD| July 1, 2003

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An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.

Bleeding Risk

Mark A. Crowther, MD, MSc| July 1, 2003

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Inadequate monitoring and management of warfarin places patient at significant risk of harm.

The Dangerous Detour

Josh Gibson, MD; David H. Taylor, MD| June 1, 2003

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En route to x-ray, suicidal patient attempts to hang herself in washroom.

XL or Smaller?

Eran Kozer, MD| June 1, 2003

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A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.

Not a Miscarriage

Lee A. Learman, MD, PhD| June 1, 2003

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A woman was told she miscarried, even though she was still pregnant.

Missed Appendicitis

James G. Adams, MD| June 1, 2003

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Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.

Inappropriate Antibiotic Use

Hilary M. Babcock, MD; Victoria J. Fraser, MD| June 1, 2003

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Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections.

Suicidal Man With Gun

Robert I. Simon, MD| May 1, 2003

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Suicidal patient who admits having firearm refuses to remove gun from home for nearly 3 months.

Central Line Clot

Adrienne G. Randolph, MD, MSc | May 1, 2003

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An infant codes due to pulmonary emboli after a central line flush.

Ectopic or Not?

Vanessa M. Givens, MD; Gary H. Lipscomb, MD| May 1, 2003

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A woman is given methotrexate prematurely for suspected ectopic pregnancy and ultimately has salpingectomy.

Bloody BP Cuff

Atul K. Madan, MD | May 1, 2003

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A blood-soaked BP cuff used on one trauma patient is re-used on the next trauma patient, with no regard to universal precautions.

The Dropped Lung

John E. Heffner, MD | May 1, 2003

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A chest x-ray incorrectly read as pleural effusion, rather than lung collapse, leads to iatrogenic pneumothorax following thoracentesis.

The 2-Week Itch

Michael Cohen, RPh, MS, ScD (hon)| April 1, 2003

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Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.

Medication Overdose

Rainu Kaushal, MD, MPH| April 1, 2003

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A boy received an overdose of phenytoin due to ambiguous use of abbreviations.

Premature or Overdue?

Jackie Thomas, MD; Mary Hannah, MD| April 1, 2003

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Incorrect dating criteria in a woman late entering prenatal care nearly leads to induction of a pre-term infant.

Which End Is Which?

Andre R. Campbell, MD| April 1, 2003

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Laparoscopic colostomy completed in reverse induces total bowel obstruction.

Another Fall

Sidney T. Bogardus, Jr., MD| April 1, 2003

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Delirious and coagulopathic patient with subdural hematomas falls out of bedtwice!

When "Psychiatric" Symptoms Are Not

Richard J. Goldberg, MD, MS| February 1, 2003

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An elderly man with delusions and progressive neurological symptoms initially attributed to psychosis is found to have metastatic cancer.

Flying Object Hits MRI

John Gosbee, MD, MS; Laura Lin Gosbee, MASc| February 1, 2003

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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.

WebM&M: Case Studies

This Month's WebM&Ms

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