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AHRQ WebM&M
Welcome to AHRQ WebM&M Did You Know
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.

Register here. Registration allows you to submit cases, participate in the Forums, and receive notice of new issues and updates to the site.
Nurses Recall Making More Errors When
Working Long Shifts or Overtime
'Did You Know' Graph

      Source


Current Cases and Commentaries   Past Issues
Medicine Surgery/Anesthesia Emergency Medicine Medical Informatics Radiology  
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

 
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