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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, 2021
Hannah Spero, MSN, APRN, Angela E. Usher, PhD, LCSW, Brian Howard MS1, and Frederick J. Meyers, MD | November 30, 2021

A 77-year-old man was diagnosed with a rectal mass. After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up. The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain. Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible. The inpatient hospice team discussed the potential role of brain radiotherapy for palliation to meet the goal of maintaining independence. The patient successfully completed a course of central nervous system (CNS) radiation, which resulted in improved strength, energy, speech, and quality of life. This case represents a perceived delay in palliative radiation, an “error” in care.

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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 (556)

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541 - 554 of 554 WebM&M Case Studies
Atul K. Madan, MD | May 1, 2003
A blood-soaked BP cuff used on one trauma patient is re-used on the next trauma patient, with no regard to universal precautions.
Vanessa M. Givens, MD; Gary H. Lipscomb, MD| May 1, 2003
A woman is given methotrexate prematurely for suspected ectopic pregnancy and ultimately has salpingectomy.
Sidney T. Bogardus, Jr., MD| April 1, 2003
Delirious and coagulopathic patient with subdural hematomas falls out of bed—twice!
Jackie Thomas, MD; Mary Hannah, MD| April 1, 2003
Incorrect dating criteria in a woman late entering prenatal care nearly leads to induction of a pre-term infant.
Michael Cohen, RPh, MS, ScD (hon)| April 1, 2003
Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.
Kaveh G. Shojania, MD| February 1, 2003
A man almost received a medication intended for another patient with the same last name in the same room.
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.