Skip to main content

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: January 7, 2022
Candice Sauder, MD, MS, MEd, FACS and Kara T Kleber, MD, MA | January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several... 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 (558)

Published Date
PSNet Publication Date
Additional Filters
541 - 558 of 558 WebM&M Case Studies
Eran Kozer, MD| June 1, 2003
A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.
John E. Heffner, MD | May 1, 2003
A chest x-ray incorrectly read as pleural effusion, rather than lung collapse, leads to iatrogenic pneumothorax following thoracentesis.
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.