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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, 2023
New
Medication Mix-Up Leads to Patient Death.
Luciano Sanchez, PharmD and Patrick Romano, MD, MPH | November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing... 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 (9)
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Displaying 1 - 9 of 9 Results
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    • One Toxic Drug Is Not Like Another
    Eric S. Holmboe, MD| February 1, 2011
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    • A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.
    The Forgotten Turn
    Susan Barbour, RN, MS, FNP| December 1, 2010
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    • Admitted to the hospital with right-hip and left-arm fractures, an elderly woman remained on the same bed from the emergency department for nearly 16 hours and developed a moderate-sized, stage 2 pressure ulcer.
    All in the History
    Christopher Fee, MD| March 21, 2009
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    • Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
    Privacy Gone Awry
    Stephen G. Pauker, MD; Susan P. Pauker, MD| May 1, 2004
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    • Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.
    Fumbled Handoff
    Arpana Vidyarthi, MD| March 1, 2004
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    • Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
    To Resuscitate or Not?
    Albert W. Wu, MD, MPH; Peter J. Pronovost, MD, PhD| January 1, 2004
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    • A patient receiving end-of-life care, whose code status was DNR, encounters a potentially life-threatening medication error.
    Another Fall
    Sidney T. Bogardus, Jr., MD| April 1, 2003
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    • Delirious and coagulopathic patient with subdural hematomas falls out of bed—twice!
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