Advanced Case Study1435378Between Sept. 30th and Oct. 14th, 2010, students and residents all over the world gathered in interprofessional teams and analyzed a complex incident that resulted in patient harm. Selected teams presented their work to IHI faculty during a series of live webinars in October.6/8/2017 6:09:00 PMKaryn Baum, MD, MSEd, Associate Professor of Medicine, University of Minnesota Reviewers: Barbara Balik, RN, EdD, Senior Faculty Member, IHI; Jonathan Finkelstein, MD, MPH STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities611813380http://www.ihi.org6/8/2017 6:09:00 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
An Extended Stay1435414A 64-year-old man with a number of health issues comes to the hospital because he is having trouble breathing. The care team helps resolve the issue, but forgets a standard treatment that causes unnecessary harm to the patient. A subsequent medication error makes the situation worse, leading a stay that is much longer than anticipated. 6/13/2017 1:33:07 PMRoss Hilliard, MD, IHI Open School Northeast Regional Chapter Leader Learning Objectives: At the end of this activity, you will be able to Explain how system failures can lead to STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities582876850http://www.ihi.org6/13/2017 1:33:07 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Happened to Josie?1435509In 2001, 18-month-old Josie King died of dehydration and a wrongly-administered narcotic at Johns Hopkins Hospital. How did this happen? Her mother, Sorrel King, tells the story and explains how Josie’s death spurred her to work on improving patient safety in hospitals everywhere. 5/26/2017 2:45:47 PMLearning Objectives: At the end of this activity, you will be able to Discuss factors that contribute to avoidable patient harm, even at renowned facilities If you plan to be a STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities13673111740http://www.ihi.org5/26/2017 2:45:47 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Happened to Alex?1435273Alex James was a runner, like his dad. One day, he collapsed during a run and was hospitalized for five days. He went through lots of tests, but was given a clean bill of health. Then, a month later, he collapsed again, fell into a deep coma, and died. His father wanted to know — what had gone wrong? Dr. John James, a retired toxicologist at NASA, tells the story of how he uncovered the cause of his son’s death and became a patient safety advocate.7/17/2017 1:55:06 PMFinding and Creating Joy in Work September 8, 2020 | IHI Online Course with Coaching To help reverse the worrying trend of burnout among health care STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies394825190http://www.ihi.org7/17/2017 1:55:06 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
The Wrong Shot: Error Disclosure (AHRQ)1435386A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers.4/8/2014 8:55:23 PMCase Study from AHRQ WebM&M   Learning Objectives: At the end of this acticity, you will be able to Describe the rationale for disclosing harmful errors to patients STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities297732150http://www.ihi.org4/8/2014 8:55:23 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Noah’s Story: Are You Listening?1435468Our newest patient story follows the care experience of four-year-old Noah and his mom, Tanya. A surgery, a series of miscommunications, and an early discharge from the hospital contribute to an adverse event that changes the family’s life forever.5/26/2017 2:11:10 PMLearning Objectives: At the end of this activity, you will be able to Recognize the importance of clear communication with patients and their families during a care experience STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities485866040http://www.ihi.org5/26/2017 2:11:10 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Low on the Totem Pole (AHRQ)1435382A medical student notices that, prior to surgery, a urinary catheter is inserted into a child without sterile prep. Being new to the OR setting, he says nothing until a few days later on rounds when the patient shows signs of infection.4/7/2014 6:57:41 PMLearning Objectives: After reading this case, students will be able to Explain the concept of authority gradient List steps that can be taken to increase communication across an STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities230881630http://www.ihi.org4/7/2014 6:57:41 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Knowing Is Not Enough1435274A healthy 57 year old man underwent a liver donation procedure. He began to manifest some tachycardia late on the second postoperative day. Early on the third post-operative day, he began to hiccup, complained of being nauseated and was pronounced dead later that day.5/24/2017 1:50:08 PMSubmitted by Dr. Paul Batalden, Professor of Pediatrics and of Community & Family Medicine, Dartmouth Medical School Learning Objectives: At the end of this activity, you will be STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies17993990http://www.ihi.org5/24/2017 1:50:08 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
The Patient and the Anesthesiologist1435471Linda Kenney went into the hospital for an ankle replacement. She came out with a host of complications resulting from a mistake that no one was willing to admit. Until Rick van Pelt, MD, her anesthesiologist, stepped forward. In this three-part video case study, you’ll find out what happened in the immediate aftermath of the surgery, watch Kenney and van Pelt describe their first meeting after the surgery, and watch Kathy Duncan, RN, and Don Berwick, MD, analyze the case.10/30/2018 4:00:05 PMDonald Berwick, MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement; Kathy Duncan, RN, Faculty, Institute for Healthcare Improvement; Linda Kenney STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities285515070http://www.ihi.org10/30/2018 4:00:05 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
X-ray Flip (AHRQ)1435387A patient comes to the emergency department with a pneumothorax on his left side. His radiograph is mistakenly labeled backwards, and the resident assigned to the patient wrongly places a chest tube on the right side.4/7/2014 6:56:41 PMCase Study from AHRQ WebM&M    Learning Objectives: At the end of this activity, you will be able to Explain why certain wrong-site errors occur in health care settings STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities180291040http://www.ihi.org4/7/2014 6:56:41 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js

~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_Default.js
~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_Default.js
~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_Default.js
~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_Default.js
~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_Default.js
~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_Default.js
~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_Default.js
~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_Default.js

© 2020 Institute for Healthcare Improvement. All rights reserved.