Glucose Roller Coaster (AHRQ)2157518A 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 PMLearning 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities169672710http://www.ihi.org4/7/2014 6:57:49 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Misread Label (AHRQ) 2157520An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.4/7/2014 6:57:09 PMCase Study from AHRQ WebM&M; Discussion questions submitted by Andrew Carson-Stevens, Medical Student, Cardiff University, Cardiff, United Kingdom; Jennifer Boehne, PharmD STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities216774600http://www.ihi.org4/7/2014 6:57:09 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Advanced Case Study2157515Between 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/Activities732563590http://www.ihi.org6/8/2017 6:09:00 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Happened to Josie?2157552In 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/Activities18553319310http://www.ihi.org5/26/2017 2:45:47 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
On Being Transparent2157578You 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 PMClick 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities417853100http://www.ihi.org4/11/2014 7:22:33 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Low on the Totem Pole (AHRQ)2157519A 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/Activities286602930http://www.ihi.org4/7/2014 6:57:41 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
When You Hear Hoofbeats, Don’t Think Zebras2157401In a new patient story, IHI Open School Academic Advisor Dr. James Moses introduces us to Lauren, an 18-year-old female who endured a painful journey through the health care system. One morning during her first semester of college in Boston, Lauren woke up with soreness in the side of her face. Several months – and a misdiagnosis later – the pain only got worse. 5/26/2017 1:59:30 PMLearning Objectives: At the end of this activity, you will be able to Describe qualities associated with patient-centered care Discuss different ways a provider can respond to STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities163051850http://www.ihi.org5/26/2017 1:59:30 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
An Insulin Overdose2157525In the midst of a high-risk surgery, the senior resident injects 100 times the correct dosage of insulin.6/13/2017 2:02:17 PM Lasic, MD, Clinical Instructor in Anesthesia, Harvard Medical School, Brigham and Women’s Hospital   Learning Objectives: At the end of this activity, you will be able to STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities244611310http://www.ihi.org6/13/2017 2:02:17 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
An Extended Stay2157423A 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/Activities795815080http://www.ihi.org6/13/2017 1:33:07 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
How Do You Apologize After a Medical Error?2157526When you make a mistake that affects a patient, what should you say? Should you apologize, or will that put you at greater risk of being sued? Lucian Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, describes how to talk with patients and families after a mistake has occurred. 5/24/2017 5:32:38 PM Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health   Learning Objectives: At the end of this activity, you will be able to STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities209711990http://www.ihi.org5/24/2017 5:32:38 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js

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