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.
New WebM&M Spotlight Cases
A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were... Read More
These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and... Read More
A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee... Read More
This case describes a man in his 70s with a history of multiple myeloma and multiple healthcare encounters for diarrhea in the previous five years, which had always been attributed to viral or unknown causes, without any... Read More
All WebM&M Spotlight Cases (18)
- Communication Improvement(10)
- Education and Training(9)
- Human Factors Engineering(9)
- Quality Improvement Strategies(5)
- Logistical Approaches(3)
- Culture of Safety(2)
- Error Reporting and Analysis(2)
- Legal and Policy Approaches(2)
- Technologic Approaches(2)
- Computerized Decision Support(1)
- Specialization of Care(1)
- Medication Safety(5)
- Discontinuities, Gaps, and Hand-Off Problems(4)
- Device-Related Complications(2)
- Medical Complications(2)
- Surgical Complications(2)
- Diagnostic Errors(1)
- Interruptions and distractions(1)
- Nonsurgical Procedural Complications(1)
- Psychological and Social Complications(1)
- Transitions of Care(1)
A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated. The error was recognized after 15 minutes of infusion, but the patient had ongoing hypotension following the inadvertent bolus. The commentary summarizes the common errors associated with administration of multiple intravenous infusions in intensive care settings and gives recommendations for reducing errors associated with co-administration of infusions.
Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.
A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Although no timeline for the transfer had been established, the patient’s code status was changed to “Do Not Resuscitate” (DNR) with a plan for him to remain in the ICU for a few days to stabilize. Unfortunately, the patient was transferred out of the ICU after the palliative care team left for the weekend and his respiratory status deteriorated. The patient died in the hospital later that week; he was never able to go home as he had wished. The associated commentary describes how care inconsistent with patient goals and wishes is a form of preventable harm, discusses the need for clear communication between care team, and the importance of providers and healthcare team members serving as advocates for their vulnerable patients.