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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Breakdown of AHRQ WebM&M; Users by Provider and Non-Provider Roles

Source

Thin Air
A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why—the patient is mistakenly receiving compressed room air.

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Commentary By:
David M. Gaba, MD

Moved Too Soon
A surgical patient and a neurosurgical patient are scheduled to be moved to different beds, the second taking the first's spot. However, the move is documented electronically before it occurs physically, and a medication error nearly ensues.

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Commentary By:
Peter Lindenauer, MD, MSc

Lap Burn
While repositioning the trocar, a surgeon places the laparoscope on a tray sitting on the patient. When she picks it back up, she notices that the drape has melted and the patient has a second-degree burn.

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Commentary By:
Kay Ball, RN, MSA

Electronic Err
After an admitting physician bases the dosages of medication on an outdated electronic medication list, the patient's heart nearly stops.

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Commentary By:
Paul C. Tang, MD

Hard to Swallow
Following a swallowing study, a speech pathologist recommends that a patient receive nothing by mouth, due to a high risk of aspiration. However, because the report is misfiled, no NPO order is implemented.

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Commentary By:
Jeffrey Driver, JD, MBA


Writers of cases selected for posting receive an honorarium.

Produced for the Agency for Healthcare Research and Quality, by a team of editors at the University of California, San Francisco with guidance from a prominent Editorial Board and Advisory Panel. The AHRQ WebM&M site was designed and implemented by DoctorQuality.