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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 (2)

1 - 2 of 2 WebM&M Case Studies
Erin Stephany Sanchez, MD, Melody Tran-Reina, MD, Kupiri Ackerman-Barger, PhD, RN, Kristine Phung, MD, Mithu Molla, MD, MBA, and Hendry Ton, MD, MS| April 29, 2020
A patient with progressive mixed respiratory failure was admitted to the step-down unit despite the physician team’s request to send the patient to the ICU. The case reveals issues of power dynamics, hierarchies, and implicit bias as young female physicians interact with experienced male members in the interdisciplinary team.
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Adrianne M Widaman, PhD, RD | December 18, 2019
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.