U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality
Provide Feedback |
Submit a Case
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 (7)
Published Date
PSNet Publication Date
Continue Education
Additional Filters
Approach to Improving Safety
Clinical Area
Error Types
Safety Target
Setting of Care
Target Audience
Why create an account for Continued Education?
Gain access to quizzes and start earning CME, CEU, or Trainee certification.
Start Earning Certifications
Displaying 1 - 7 of 7 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.
    Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression
    Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP| May 27, 2020
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A patient with multiple comorbidities and chronic pain was admitted for elective spinal decompression and fusion. The patient was placed on a postoperative patient-controlled analgesia (PCA) for pain control and was later found unresponsive. The case illustrates risks associated with opioid administration through PCA, particularly among patients at high risk for postoperative opioid-induced respiratory depression.
    Discharged with IV antibiotics: When issues arise, who manages the complications?
    Monica Donnelley, PharmD, Thomas Joseph Gintjee, PharmD, and James Go, PharmD| February 26, 2020
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • This commentary involves two patients who were discharged from the hospital to skilled nursing facilities on long-term antibiotics. In both cases, there were multiple errors in the follow up management of the antibiotics and associated laboratory tests. This case explores the errors and offers discussion regarding the integration of a specialized Outpatient Parenteral Antimicrobial Therapy (OPAT) team and others who can mitigate the risks and improve patient care.
    E-prescribing: E for error?
    Elisa W. Ashton, PharmD| February 1, 2012
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • After entering an electronic prescription for the wrong patient, the clinic nurse deleted it, assuming that would cancel the order at the pharmacy. However, the prescription went through to the pharmacy, and the patient received it.
    Bad Writing, Wrong Medication
    Beth Devine, PharmD, MBA, PhD| April 1, 2010
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A medication dispensing error causes nausea, sweating, and irregular heartbeat in an elderly man with a history of cardiac arrhythmia. Investigation reveals that the patient was given thyroid replacement medication instead of antiarrhythmic medication.
    Medication Reconciliation: Whose Job Is It?
    Eric G. Poon, MD, MPH| September 1, 2007
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Hospitalized for surgery, a woman with a history of seizures was given an overdose of the wrong medicine due to multiple errors, including an inaccurate preadmission medication list, failure to verify medication history, and uncoordinated information systems.
    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.
    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