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
This case involves a procedural sedation error in a 3-year-old patient who presented to the... Read More
This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors... Read More
This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical... Read More
All WebM&M: Case Studies (1)
A 69-year-old man with cognitive impairment and marginal housing was admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). After a four-day admission, the physician arranged for discharge and transport to residential care home and arranged for Meds-to-Beds (M2B), a service that collaborates with a local commercial pharmacy to deliver discharge medications to the bedside prior to the patient leaving the hospital. The medication pick-up was delayed for several hours and there were miscommunications among the pharmacy, social worker, and physician. Ultimately, the patient was discharged without his medications and was readmitted five hours later with dyspnea and hypoxia. The commentary suggests that 7- versus 30-day readmission rates may be more reflective of hospital readmission mitigation efforts and discusses the value of Meds-to-Beds (M2B) programs in improving adherence to medication regimens during transitions of care