| Misread Label (AHRQ) | 55971 | | 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 | 19294 | 245 | | | | | | 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 |
| The Wrong Shot: Error Disclosure (AHRQ) | 55974 | | 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 | 35543 | 285 | | | | | | 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 |
| Three Ways to Create Psychological Safety in Health Care | 55940 | | How can leaders ― with or without formal authority ― create psychological safety in health care? In a short video, Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, describes three key actions to foster a psychologically safe work environment. | 8/29/2017 8:37:30 PM | IHI Africa Forum 2021
4–6 May 2021 | Online
Featuring presenters from throughout Africa and across the globe, this conference addresses unique | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo | 20918 | 179 | | | | | | 0 | http://www.ihi.org | 8/29/2017 8:37:30 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| 'Sue, Can You Smile?' | 55987 | | In a new patient story, you’ll meet Sue, a nurse who undergoes several operations to remove a mass behind her ear, resulting in an adverse event. As you follow Sue’s story, you’ll be prompted to stop along the way to consider a number of questions about making mistakes, communication after adverse events, and the patient, family, and caregiver perspectives. When you get to the end of the story, you’ll hear from Sue and her surgeon, Dr. Rae, as they look back on the experience nearly seven years later. | 5/26/2017 2:39:58 PM | Learning Objectives: At the end of this activity, you will be able to Explain the importance of keeping patients’ families informed about the care experience When you get to the end | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 10240 | 146 | | | | | | 0 | http://www.ihi.org | 5/26/2017 2:39:58 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| The Patient and the Anesthesiologist | 56031 | | Linda 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 PM | Donald Berwick, MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement; Kathy Duncan, RN, Faculty, Institute for Healthcare Improvement; Linda Kenney | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 33327 | 201 | | | | | | 0 | http://www.ihi.org | 10/30/2018 4:00:05 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| What Are the Dangers of Alert Fatigue? | 56001 | | In a new IHI Open School short, patient safety expert Dr. Bob Wachter talks about the dangers of alert fatigue in health care. | 10/10/2017 3:44:42 PM | This annual meeting is the must-attend event for those who continue to shape smarter, safer care for patients wherever it’s provided – from the hospital to outpatient settings to | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 19491 | 118 | | | | | | 0 | http://www.ihi.org | 10/10/2017 3:44:42 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| 'Enjoy What You Have Left of Your Life' | 55891 | | In a new patient story, you’ll hear the story of a nurse named Christiane who becomes a patient after she is diagnosed with an inoperable brain tumor in the midst of her career. As you follow Christiane’s story, you’ll be prompted to stop along the way to consider a number of questions about her care and challenging transition from provider to patient. When you get to the end of the story, you’ll hear from Christiane and get her perspective on the experience. | 5/26/2017 1:50:23 PM | Objectives: At the end of this activity, you will be able to Discuss why it can be challenging for health care providers to care for themselves List at least two examples of unsafe | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 27712 | 241 | | | | | | 0 | http://www.ihi.org | 5/26/2017 1:50:23 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Why Is Psychological Safety So Important in Health Care? | 55941 | | 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 Africa Forum 2021
4–6 May 2021 | Online
Featuring presenters from throughout Africa and across the globe, this conference addresses unique | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo | 28602 | 237 | | | | | | 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 |
| Low on the Totem Pole (AHRQ) | 55970 | | 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 | 26755 | 202 | | | | | | 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 |
| One Dose, Fifty Pills (AHRQ) | 55972 | | 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 | 17959 | 308 | | | | | | 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 |
