| Low on the Totem Pole (AHRQ) | 2157519 | | 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 | 29347 | 365 | | | | | | 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 |
| Misread Label (AHRQ) | 2157520 | | 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 | 22337 | 279 | | | | | | 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 |
| Glucose Roller Coaster (AHRQ) | 2157518 | | 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 | 17527 | 233 | | | | | | 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 |
| The Wrong Shot: Error Disclosure (AHRQ) | 2157523 | | 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 | 37396 | 207 | | | | | | 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 |
| How Can Disruptive Behavior Be Harmful? | 2157430 | | Physician Kevin Stewart explains how he accidentally hurt a patient when he was trying to avoid a confrontation with his foul-tempered supervisor. He offers advice for people who find themselves on the receiving end of disrespectful behavior. | 5/26/2017 1:50:32 PM | Stewart, MB, FRCP; Medical Director, Winchester Hospital, UK; Health Foundation/IHI Quality Improvement Fellow Learning Objectives: At the end of this activity, you will be able | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 8915 | 39 | | | | | | 0 | http://www.ihi.org | 5/26/2017 1:50:32 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Mutiny | 2157576 | | The behavior of a superior starts to put your patients at risk. What would you do? The University of Rochester’s Dr. Paul Griner presents the final installment in a series of case studies for the IHI Open School. | 4/11/2014 7:51:52 PM | Click here to view all of Dr. Paul Griner's case studies Dr. Paul Griner, Professor Emeritus of Medicine at the University of Rochester Learning Objectives: At the end of this | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 37501 | 250 | | | | | | 0 | http://www.ihi.org | 4/11/2014 7:51:52 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| What Can a Zoo Teach Health Care about Patient Safety? | 2157605 | | Kathy Duncan goes behind the scenes to learn about the Central Florida Zoo's safety procedures for handling snakes. | 5/24/2017 5:23:08 PM | Learning Objectives: At the end of this activity, you will be able to List three principles of reliable systems Explain how the Central Florida Zoo uses these three principles in | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo | 46991 | 423 | | | | | | 0 | http://www.ihi.org | 5/24/2017 5:23:08 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Why Is Psychological Safety So Important in Health Care? | 2157494 | | Why is psychological safety in health care so important? In a short video, Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, describes four specific outcomes associated with a psychologically safe work environment. | 8/29/2017 8:37:33 PM | IHI Forum 2021
December 5–8, 2021 | Virtual Conference
The IHI Forum is a four-day conference that has been the home of quality improvement (QI) in | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo | 32372 | 303 | | | | | | 0 | http://www.ihi.org | 8/29/2017 8:37:33 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| What Is a Culture of Safety? | 2157458 | | Dr. David Bates, a world-renowned patient safety expert, describes a culture of safety and what organizations can do to foster it. | 5/24/2017 5:29:43 PM | David W. Bates, MD, MSc, Senior Vice President and Chief Innovation Officer, Brigham and Women’s Hospital Learning Objectives: At the end of this activity, you will be able to | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 46695 | 277 | | | | | | 0 | http://www.ihi.org | 5/24/2017 5:29:43 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| One Dose, Fifty Pills (AHRQ) | 2157521 | | Told to give a patient one gram of steroids, an intern mistakenly orders fifty 20-mg pills. Although a pharmacist questions the order, the intern insists that the medication be given as ordered. | 4/7/2014 6:56:59 PM | Learning Objectives: At the end of this activity, you will be able to Identify the risks involved with improper supervision in a health care setting She suggested to the intern that | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 21767 | 260 | | | | | | 0 | http://www.ihi.org | 4/7/2014 6:56:59 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
