CSI:ME Case Studies in Medical Errors


Internet Enduring Material Sponsored by the Stanford University School of Medicine. Presented by the Department of Quality and Clinical Effectiveness at Stanford Health Care.

Course Description

This CME activity aims to improve the practicing physicians’ and other health care providers’ knowledge about the types of medical errors that can occur and different methods of mitigating and/or preventing these events from occurring by utilizing The Joint Commission guidelines and standards pertaining to the National Patient Safety Goals.  The activity is a web-enabled, interactive program that permits the participant to work on medical events by investigating and analyzing root causes and/or contributing factors to comprehend how medical errors can occur. These are the skills that can be utilized on a daily basis by healthcare providers to ensure safe patient care. 


Intended Audience

This course is designed to meet the educational needs of physicians and nurses and other interested allied health professionals in all specialties.


Dates, Duration and Fee

  • Release Date: November 15, 2018
  • Expiration Date: November 15, 2021
  • Estimated Time to Complete: 1.25 Hours
  • CME Credits Offered: 1.25
  • Registration Fee: FREE

To Obtain CME Credits

  • Review the information below and complete the entire activity.
  • Complete the CME Post-test, CME Assessment Survey, and CME Activity Completion Statement at the end of the activity.
  • You must receive a score of 75% or higher on the post-test in order to receive a certificate. You will have two attempts to answer each multiple-choice question (or one attempt for questions with only two options) to pass the post-test.
  • Once you attest to completing the entire online activity and have scored 75% or higher on the post-test, your certificate will be generated automatically and will be available on your Dashboard page.
  • Physicians will be awarded AMA PRA Category 1 Credits™. All other participants will receive a Certificate of Participation.

Learning Objectives

At the conclusion of this activity, participants should be able to:

  • Integrate NPSG requirements in clinical practice in the areas of patient identification, Universal Protocol, labeling and medication reconciliation.
  • Develop practical skills to improve team communication and apply these skills when medical errors occur and to prevent medical errors in the future, i.e. immediate feedback.
  • Evaluate root causes and contributing factors that lead to various medical errors.
  • Develop skills to apply in practice the appropriate procedures or steps to assure that such events are prevented in the future.




Case 1: Wrong Site Procedure

Case 2: Mysterious Reaction

Case 3: Bloody Mistake

Case 4: Therapeutic Duplication

Course Wrap-Up

Resources and References



The following planners and author have indicated that that they have no relationships with industry to disclose relative to the content of this activity:

Joseph Hopkins, MD, MMM
Clinical Professor, Medicine - Primary Care and Population Health
Associate Chief Medical Officer
Stanford Health Care
Course Director

Steven Chinn, DPM, MS, MBA
Administrative Director, Accreditation and Regulatory Affairs
Interim Patient Safety Officer
Stanford Health Care

Clinical Associate Professor
Division of Primary Care and Population Health
Department of Medicine
Stanford School of Medicine
Co-Course Director



Technical Design and Development

Hardware/Software Requirements

  • Computer with Internet connection
  • Current version of Chrome, Firefox or Safari browser. You must have javascript enabled.

Accreditation and Designation of Credits

The Stanford University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Stanford University School of Medicine designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The American Nurses Credentialing Center (ANCC) accepts AMA PRA Category 1 Credit TM from organizations accredited by the ACCME. Please check with your state’s credentialing board for their requirements.

Commercial Support Acknowledgement

Stanford University School of Medicine has received and has used undesignated program funding from Pfizer, Inc. to facilitate the development of innovative CME activities designed to enhance physician competence and performance and to implement advanced technology. A portion of this funding supports this activity.


Cultural and Linguistic Competency

California Assembly Bill 1195 requires continuing medical education activities with patient care components to include curriculum in the subjects of cultural and linguistic competency. It is the intent of the bill, which went into effect July 1, 2006, to encourage physicians and surgeons, CME providers in the State of California and the Accreditation Council for Continuing Medical Education to meet the cultural and linguistic concerns of a diverse patient population through appropriate professional development. The planners and speakers of this CME activity have been encouraged to address cultural issues relevant to their topic area. The Stanford University School of Medicine Multicultural Health Portal also contains many useful cultural and linguistic competency tools including culture guides, language access information and pertinent state and federal laws.

CME Privacy Policy


If you are having problems, contact the CME Online support team at CMEonline@stanford.edu and we will follow-up with you to resolve your issue.


Institute of Medicine “To Err is Human” report:  http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

Chassin M and Loeb J, “The Journey to High Reliability”  The Milbank Quarterly, Vol. 91, No. 3, 2013 (pp. 459–490)

National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.

Joint Commission Sentinel Event Policy and Procedure

Joint Commission Hospital National Patient Safety Goals 2018

Heidi B. King, MS, CHE, James Battles, PhD, David P. Baker, PhD, Alexander Alonso, PhD, Eduardo Salas, PhD, John Webster, MD, MBA, Lauren Toomey, RN, BSBA, MIS, and Mary Salisbury, RN, MSN.  “TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety”, Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools).  Henriksen K, Battles JB, Keyes MA, et al., editors.

Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug.

Martin A Makary and Michael Daniel, “Medical error—the third leading cause of death in the US”’
BMJ 2016;353:i2139 (Published 03 May 2016)


More bibliographic information can be found in the Resources and References section.

©2018 Stanford University School of Medicine

Course Details

  • Ongoing registration for this self-paced course is available until November 15, 2021
  • Estimated Time to Complete: 1.25 hours
  • CME Credits Offered: 1.25
  • Registration Fee: FREE

Contact Information

If you are having problems, contact the CME Online support team at CMEonline@stanford.edu and we will follow-up with you to resolve your issue.

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