AHRQ WebM&M;: Morbidity & Mortality Rounds on the Web

the online journal and forum on patient safety and health care quality. This site features expert analysis of medical errors reported anonymously by our readers, interactive learning modules on patient safety ("Spotlight Cases"), and forums for online discussion. CME credit is available.

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Nurses Recall Making More Errors When
Working Long Shifts or Overtime

Source

Doctor, Don't Treat Thyself
An ill physician arrives at the ED for evaluation of shortness of breath. As it is past midnight and he is the only radiologist around, he reads (and misinterprets) his own x-ray.

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Commentary By:
Elin Olaug Rosvold, MD, PhD

Poor Prognosis
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.

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Commentary By:
Elizabeth Lamont, MD, MS

Caution, Interrupted
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.

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Commentary By:
Robert Wears, MD, MS

Security Lapse
A medical student discovers that a hospital’s radiology records are accessible via Internet, without any security, and struggles with whether and to whom to report the obvious HIPAA violation.

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Commentary By:
Daniel Mason, MD

Reaction to Dye
Prior to a CT scan, a patient states that he is not allergic to x-ray dye. Soon after injection, he goes into anaphylactic shock.

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Commentary By:
Richard Cohan, MD


Writers of cases selected for posting receive an honorarium.

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