| Advanced Case Study | 1435378 | | Between 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 PM | Karyn 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 58283 | 676 | | | | | | 0 | http://www.ihi.org | 6/8/2017 6:09:00 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| The Wrong Shot: Error Disclosure (AHRQ) | 1435386 | | A 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 PM | Case 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 27837 | 380 | | | | | | 0 | http://www.ihi.org | 4/8/2014 8:55:23 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Noah’s Story: Are You Listening? | 1435468 | | Our 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 PM | Learning 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 44412 | 1672 | | | | | | 0 | http://www.ihi.org | 5/26/2017 2:11:10 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Low on the Totem Pole (AHRQ) | 1435382 | | A 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 PM | Learning 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 21903 | 264 | | | | | | 0 | http://www.ihi.org | 4/7/2014 6:57:41 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| What Happened to Josie? | 1435509 | | In 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 PM | Learning 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 127369 | 1774 | | | | | | 0 | http://www.ihi.org | 5/26/2017 2:45:47 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Misread Label (AHRQ) | 1435383 | | An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity. | 4/7/2014 6:57:09 PM | Case Study from AHRQ
WebM&M; Discussion questions submitted
by Andrew
Carson-Stevens, Medical Student, Cardiff
University, Cardiff, United Kingdom;
Jennifer Boehne, PharmD | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 15280 | 243 | | | | | | 0 | http://www.ihi.org | 4/7/2014 6:57:09 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Don't Push (AHRQ) | 1435380 | | Inappropriate use of IV haloperidol to manage psychosis in an AIDS patient causes polymorphic v-tach ('torsade de pointes'), necessitating a transvenous pacemaker. | 4/7/2014 6:58:08 PM | Learning Objectives: At the end of this activity, you will be able to Describe the delicate balance of effectiveness and safety when it comes to powerful drugs | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 13443 | 159 | | | | | | 0 | http://www.ihi.org | 4/7/2014 6:58:08 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| An Extended Stay | 1435414 | | A 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 PM | Ross 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 53771 | 1072 | | | | | | 0 | http://www.ihi.org | 6/13/2017 1:33:07 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Glucose Roller Coaster (AHRQ) | 1435381 | | A woman hospitalized for congestive heart failure (with no history of diabetes) is given several rounds of insulin and D50, after repeated blood tests show her glucose to be dangerously high, then dangerously low. Turns out, the blood samples were drawn incorrectly and the signouts were incomplete. | 4/7/2014 6:57:49 PM | Learning Objectives: At the end of this activity, you will be able to Explain why good communication is critical to patient safety Description: A woman hospitalized for congestive | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 13485 | 159 | | | | | | 0 | http://www.ihi.org | 4/7/2014 6:57:49 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| On Being Transparent | 1435469 | | You are the CEO and a patient in your hospital dies from a medication error. What do you do next? The University of Rochester’s Dr. Paul Griner presents the fourth in a series of case studies. | 4/11/2014 7:22:33 PM | Click here to view all of Dr. Paul Griner's case studies . Paul Griner, Professor Emeritus of Medicine at the University of Rochester, presents the fourth in a series of case studies | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 29594 | 359 | | | | | | 0 | http://www.ihi.org | 4/11/2014 7:22:33 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
