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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: August 5, 2022
Samson Lee, PharmD, and Mithu Molla, MD, MBA | August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to... 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 (16)

1 - 16 of 16 WebM&M Case Studies
Lamia S. Choudhury, MS1 and Catherine T Vu, MD| January 29, 2020
Multiple patients were admitted to a large tertiary hospital within a 4-week period and experienced patient identification errors. These cases highlight important systems issues contributing to this problem and the consequences of incorrect patient identification.
Allan S. Frankel, MD; Kathryn C. Adair, PhD; and J. Bryan Sexton, PhD| June 1, 2019
A proceduralist went to perform ultrasound and thoracentesis on an elderly man admitted to the medicine service with bilateral pleural effusions. Unfortunately, he scanned the wrong patient (the patient had the same last name and was in the room next door). When the patient care assistant notified the physician of the error, he proceeded to scan the correct patient. He later nominated the assistant for a Stand Up for Safety Award.
Gregory A. Filice, MD| December 1, 2016
An older woman experienced acute kidney injury after being prescribed a nephrotoxic medication (amphotericin) intended for the ICU patient in the next bed. Caring for both patients, the covering resident entered the medication order for the wrong patient despite a policy requiring infectious disease consultation to prescribe IV amphotericin.
Jason S. Adelman, MD, MS| October 1, 2013
After a hospitalized patient died, the intern went to fill out the death certificate and notify the family. However, he picked up the chart of a different patient and mistakenly notified another patient's wife that her husband had died. He soon realized he'd notified the wrong family.
Abigail Zuger, MD| June 1, 2011
An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.
Kerm Henriksen, PhD; Kendall K. Hall, MD, MS| June 1, 2011
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
Leslie W. Hall, MD| October 1, 2008
Orthopedic surgeons rounding on an elderly Cantonese-speaking woman recommend conservative, nonsurgical treatment for her broken hip, as their examination noted that the patient was able to walk. Given that strict bed rest orders were in place for this patient, a medical intern found the note peculiar. Further investigation revealed that the surgeons had actually walked the patient's roommate, another Cantonese-speaking woman.
Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH| May 1, 2006
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Dennis S. O'Leary, MD; William E. Jacott, MD| December 1, 2004
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
Neil A. Holtzman, MD, MPH| December 1, 2004
A pregnant woman is offered genetic testing for herself and her husband. Although he declines, the next time he undergoes routine testing, the phlebotomist overrides the consent in the computerized record and runs the test anyway.
Peter Lindenauer, MD, MSc| October 1, 2004
A surgical patient and a neurosurgical patient are scheduled to be moved to different beds, the second taking the first's spot. However, the move is documented electronically before it occurs physically, and a medication error nearly ensues.
Mark V. Williams, MD| July 1, 2004
A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead.
Darrell Campbell, Jr., MD| June 1, 2004
Despite persuasion from a surgical resident that her mother's life was in danger, a patient's daughter refuses consent for surgery on her mother. This was wise, since the procedure was intended for a different patient with the same unusual surname.
Albert W. Wu, MD, MPH; Peter J. Pronovost, MD, PhD| January 1, 2004
A patient receiving end-of-life care, whose code status was DNR, encounters a potentially life-threatening medication error.
Marilynn M. Rosenthal, PhD| July 1, 2003
An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.