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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)

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1 - 2 of 2 WebM&M Case Studies
Lisa Strate, MD, MPH, and Sophia Swanson, MD| September 1, 2017
An older man with Crohn disease was admitted for abdominal pain and high stool output from his ileostomy. Despite blood passing from his ostomy and a falling hemoglobin level, the patient was not given a timely blood transfusion.
Manish S. Patel, MD, and Jeffrey L. Carson, MD| November 1, 2012
At a skilled nursing facility, an elderly woman with myelodysplastic syndrome was found to be mildly anemic, and her oncologist arranged for her to be sent to the hospital and transfused with 2 units of blood. Less than 1 hour after the second unit of blood finished transfusing, the patient rapidly worsened and had a respiratory arrest.