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.

New WebM&M Spotlight Cases

All WebM&M Spotlight Cases (182)
Published Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Displaying 51 - 60 of 182 WebM&M Spotlight Cases
  • 10
  • 20
  • 50
  • 100
    • A Painful Medication Reconciliation Mishap
    Roger Chou, MD| January 1, 2018
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A woman who had been taking naltrexone to treat alcohol use disorder was discharged to a skilled nursing facility (SNF) on opioids for pain following spinal fusion surgery. Although her naltrexone was held at the hospital in anticipation of starting opioids for pain control, the clinician performing medication reconciliation at the SNF overrode the drug–drug interaction alert and restarted the naltrexone. The SNF providers did not realize that the naltrexone blocked the pain-relieving effect of the opioids.
    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.
    Palliative Care: Comfort vs. Harm
    Ralf Jox, MD, PhD| November 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • An older man admitted for the third time in 4 weeks for an exacerbation of congestive heart failure expressed his wishes to focus on comfort and pursue hospice care. Comfort measures were initiated and other treatments were stopped. The care team wrote for a standing dose of IV hydromorphone every 4 hours. The night shift nurse administered the scheduled dose at 3:00 AM. At 7:00 AM, the palliative care attending found the patient obtunded, with shallow respirations and a low respiratory rate.
    Translating From Normal to Abnormal
    Anne M. Turner, MD, MLIS, MPH| October 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • A Spanish-speaking woman presented to an urgent care clinic complaining of headache and worsening dizziness, for which the treating clinician ordered an MRI. When the results came in with no concerning findings later that day, the provider used Google Translate to write a letter informing the patient of the results. The patient interpreted the letter to mean that the results were concerning. This miscommunication led to patient distress and extra visits to both urgent care and the emergency department.
    Transfusion Thresholds in Gastrointestinal Bleeding
    Lisa Strate, MD, MPH, and Sophia Swanson, MD| September 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • An older man with Crohn disease was admitted for abdominal pain and high stool output from his ileostomy. Despite blood passing from his ostomy and a falling hemoglobin level, the patient was not given a timely blood transfusion.
    Despite Clues, Failed to Rescue
    Amir A. Ghaferi, MD, MS| August 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Admitted to gynecology due to excess bleeding and low hemoglobin after elective surgery, an older woman developed severe pain, nausea, and new-onset atrial fibrillation. She was moved to the telemetry unit where cardiologists treated her, and she had episodes of bloody vomit. Intensivists consulted, but the patient arrested while being transferred to the ICU and died despite maximal efforts.
    Pseudo-obstruction But a Real Perforation
    Shirley C. Paski, MD, MSc, and Jason A. Dominitz, MD, MHS| July 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Following an uncomplicated surgery, an older man developed acute colonic pseudo-obstruction refractory to conservative management. During a decompression colonoscopy, the patient's colon was perforated.
    The Perils of Contrast Media
    Umar Sadat, MD, PhD, and Richard Solomon, MD| June 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.
    Diagnostic Delay in the Emergency Department
    Kyle Marshall, MD, and Hardeep Singh, MD, MPH| May 1, 2017
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Emergency department evaluation of a man with morbid obesity presenting with abdominal pain revealed tachycardia, hypertension, elevated creatinine, and no evidence of cholecystitis. Several hours later, the patient underwent CT scan; the physicians withheld contrast out of concern for his acute kidney injury. The initial scan provided no definitive answer. Ultimately, physicians ordered additional CT scans with contrast and diagnosed an acute aortic dissection.
    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.
    Back To Top
    Terms and Conditions | Privacy Policy | External Link Disclaimer

    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