U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality
Provide Feedback |
Patient Safety Network
Search Tips

Continuing Education

What is PSNet Continuing Education?

PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/ Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of California, Davis (UCD) Health Office of Continuing Medical Education. 
 

Each WebM&M Spotlight Case and Commentary is certified for the AMA PRA Category 1™ and Maintenance of Certification (MOC) through the American Board of Internal Medicine by the Office of Continuing Medical Education (OCME) at UCD, Health. 
 

Learn more about how to earn credit from UCD 

UCD's CME Security and Privacy 

 

How does it work?

Earn CME or MOC credit and trainee certification by successfully completing quizzes based on Cases & Commentaries. 

  • Individuals have two attempts at each quiz to achieve a passing score of 80% or higher in order to earn credit.
  • If you fail a quiz twice, the quiz will become unavailable, but the Spotlight case will be available as read-only.
  • Spotlight Cases older than three years continue to be available as read-only, but their associated quizzes have been disabled.
  • If you have questions specifically regarding University of California San Francisco (UCSF) CME/CEU, including registration, accreditation, or content, please email us at info@ocme.ucsf.edu.

New WebM&M Spotlight Cases

All WebM&M Spotlight Cases (11)
Published Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Displaying 1 - 10 of 11 WebM&M Spotlight Cases
  • 10
  • 20
  • 50
  • 100
    • When Patients and Providers Speak Different Languages
    Leah S. Karliner, MD, MAS| April 1, 2018
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Although the electronic health record noted that a woman required a Spanish interpreter to communicate with providers, no in-person interpreter was booked in advance. A non–Spanish-speaking physician attempted to use the clinic's phone interpreter services to communicate with the patient, but poor reception prevented the interpreter and patient from hearing each other. The patient called her husband, but he was unavailable. Eventually, a Spanish-speaking medical assistant was able to interpret for the visit. Fortunately, the physician was able to determine that the patient required further cardiac testing before proceeding with a planned elective surgery.
    Dying in the Hospital With Advanced Dementia
    Craig A. Umscheid, MD, MSCE; John D. McGreevey, III, MD; and S. Ryan Greysen, MD, MHS, MA| December 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Found unconscious at home, an older woman with advanced dementia and end-stage renal disease was resuscitated in the field and taken to the emergency department, where she was registered with a temporary medical record number. Once her actual medical record was identified, her DNR/DNI status was identified. After recognizing this and having discussions with the family, she was transitioned to comfort care and died a few hours later. Two months later, the clinic called the patient's home with an appointment reminder. The primary care physician had not been contacted about the patient's hospitalization and the electronic record system had not listed the patient as deceased.
    Engaging Seriously Ill Older Patients in Advance Care Planning
    Daren K. Heyland, MD, MSc| April 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • When a 94-year-old woman presented for routine primary care, the intern caring for her discovered that the patient's code status was "full code" and that there was no documentation of discussions regarding her wishes for end-of-life care. The intern and his supervisor engaged the patient in an advance care planning discussion, during which she clarified that she would not want resuscitation or life-prolonging measures.
    The Pains of Chronic Opioid Usage
    Laxmaiah Manchikanti, MD, and Joshua A. Hirsch, MD| September 1, 2013
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Hospitalized for pneumonia and asthma, a man with chronic pain was found to be using pain medications not prescribed to him. During his hospitalization, the pain service was consulted and changed his medications to better control the pain. Five days after discharge, the patient died, presumably from an unintentional overdose of his old and new prescriptions.
    Transfer Troubles
    Isla M. Hains, PhD| June 1, 2012
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • An elderly woman was transferred to a tertiary hospital for surgical repair of hip fracture, without complete information or records. The receiving surgeons were not informed that she had a cardiac arrest during induction of anesthesia at the community hospital. Surgery proceeded, but the patient died a few days later.
    Postdischarge Follow-Up Phone Call
    Michelle Mourad, MD, and Stephanie Rennke, MD| March 1, 2012
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A woman hospitalized with community-acquired pneumonia was discharged home on antibiotics. Over the next few days, her symptoms worsened, but she was unable to obtain an appointment with her primary physician. The hospital called the patient that day to follow up, determined that she needed a different antibiotic, and prevented a readmission.
    How Do Providers Recover From Errors?
    Colin P. West, MD, PhD| January 1, 2008
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated.
    Failure to Report
    Patrice L. Spath, BA, RHIT| March 1, 2007
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error.
    The Wet Read
    Ronald L. Arenson, MD| March 1, 2006
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A patient with metastatic cancer admitted for pain control develops acute shortness of breath. The overnight resident reads the CT as a large pulmonary embolism, but the next morning, the attending reads it differently.
    Discharge Fumbles
    Alan Forster, MD, MSc| December 1, 2004
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge.
    Back To Top
    Terms and Conditions | Privacy Policy | External Link Disclaimer | RSS Feed

    Connect With Us

    Facebook Twitter You Tube LinkedIn

    Sign up for Email Updates

    Agency for Healthcare Research and Quality

    5600 Fishers Lane
    Rockville, MD 20857
    Telephone: (301) 427-1364

    Submit Your Innovations