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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: April 26, 2023
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 WebM&M Case Studies
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    • Wrong-side Bedside Paravertebral Block: Preventing the Preventable
    Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS| April 1, 2017
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    • An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.
    Say It Again
    Kerm Henriksen, PhD; Kendall K. Hall, MD, MS| June 1, 2011
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    • 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.
    Mother's Milk, but Whose Mother?
    Dorothy Dougherty, RN| November 1, 2010
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    • A hospitalized 2-month-old infant is fed breast milk from another infant's mother after the wrong bottle is pulled from the ward's refrigerator.
    Right Patient, Wrong Sample
    Michael Astion, MD, PhD | December 1, 2006
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    • A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.
    Mark My Limb
    Dennis S. O'Leary, MD; William E. Jacott, MD| December 1, 2004
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    • Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
    Moved Too Soon
    Peter Lindenauer, MD, MSc| October 1, 2004
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    • 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.
    Transfusion "Slip"
    Harold S. Kaplan, MD| February 1, 2004
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    • Blood typing tubes for a married couple brought to an ED after a trauma are labeled with the opposite stickers. By coincidence, the wife's blood type was already on file. An alert blood-bank technologist catches the mistake.
    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.
    Check the Wristband
    Marilynn M. Rosenthal, PhD| July 1, 2003
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    • An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.
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