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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 (5)
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    • Spotlight: Mistaken Attribution, Diagnostic Misstep
    Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD| January 1, 2019
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    • A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone. She was transferred to the ICU of the hospital, where a chest CT scan revealed bilateral pulmonary emboli (explaining the tachycardia and hypoxia), and clinicians also diagnosed neuroleptic malignant syndrome (a rare and life-threatening reaction to some psychiatric medications).
    Cultural Dimensions of Depression
    J. David Kinzie, MD| March 1, 2012
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    • Admitted to the hospital complaining of difficulty breathing and swallowing, a Vietnamese man was diagnosed with reflux disease and an outpouching of the esophagus. The patient was anxious and repeatedly stated that he was "dying" from his physical ailments. During a gastroenterology consultation, the patient ran to the restroom and jumped out the window, killing himself.
    The Deadly Duo
    José R. Maldonado, MD| October 1, 2010
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    • A man prescribed a tricyclic antidepressant and an antipsychotic medication was found unconscious and unresponsive at home and was brought to the emergency department (ED). An electrocardiogram showed potentially dangerous heart rhythms.
    Crossing the Borderline
    John M. Oldham, MD| December 1, 2006
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    • A young woman with borderline personality disorder hospitalized following a suicide attempt is allowed to leave the hospital and attempts suicide again.
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