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 (6)
Published Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Displaying 1 - 6 of 6 WebM&M Spotlight Cases
  • 10
  • 20
  • 50
  • 100
    • When the Indications for Drug Administration Blur
    Julia Munsch, PharmD and Amy Doroy, PhD, RN | June 24, 2020
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia. This case illustrates the importance of medication reconciliation upon transition of care, careful implementation of medication orders in their entirety, assessment of patient response and consideration of whether an administered medication is working effectively, accurate and complete documentation and communication, and the impact of limited resources during night shift.
    Take the Quiz
    What Happened on Telemetry?
    by Kristin E. Sandau, PhD, RN, and Marjorie Funk, PhD, RN| April 1, 2019
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • An elderly woman with a history of dementia, chronic obstructive pulmonary disease, hypertension, and congestive heart failure (CHF) was brought to the emergency department and found to meet criteria for sepsis. Due to her CHF, she was admitted to a unit with telemetry monitoring, which at this institution was performed remotely. When the nurse came to check the patient's vital signs several hours later, she found the patient to be unresponsive and apneic, with no palpable pulse. A Code Blue was called, but the patient died. Although the telemetry technician had recognized progressive bradycardia and called the hospital floor several minutes before the code, he was placed on hold because the nurse was busy with another patient. While he was holding, he observed worsening bradycardia, eventually transitioning to asystole, and tried to redial the unit, but no one answered.
    Treatment Challenges After Discharge
    Chase Coffey, MD, MS| November 1, 2010
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.
    Elopement
    Debra Gerardi, RN, MPH, JD| December 1, 2007
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • An inpatient missing from his room is found several hours later outside the emergency department. Despite having arrived at the ED in a hospital gown with an inpatient ID bracelet, the patient is treated in the ED and discharged.
    Do Not Disturb!
    F. Daniel Duffy, MD; Christine K. Cassel, MD| October 1, 2007
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
    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