| The Wrong Shot: Error Disclosure (AHRQ) | 2297446 | | 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 | 41606 | 302 | | | | | | 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 |
| Learning from Medical Errors (Part 1) | 2297574 | | A patient suffers horrible burns. An operation takes twice as long as it should. A child dies from internal bleeding. All because a doctor, a nurse, or another care provider made a mistake. In this video, prominent clinicians describe the errors that still haunt them today — and point out ways those errors could have been prevented. | 5/26/2017 2:12:52 PM | Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health; Kathy Duncan, RN, 5 Million Lives Campaign Faculty, Institute for Healthcare Improvement | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 49052 | 185 | | | | | | 0 | http://www.ihi.org | 5/26/2017 2:12:52 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Misread Label (AHRQ) | 2297497 | | 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 | 24725 | 191 | | | | | | 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 |
| Learning from Medical Errors (Part 2) | 2297575 | | A baby falls gravely ill after a botched blood transfusion. A student nearly commits a medication error. A patient dies after a clumsy surgery. In this video, current and former clinicians (including IHI’s Former CEO Don Berwick) describe the errors that still haunt them today — and point out ways those errors could have been prevented. | 5/26/2017 2:13:03 PM | Frankel, MD, Director of Patient Safety, Partners Healthcare; Kevin Knoblock, Student, MSN/Nurse Practitioner Program, MGH Institute of Health Professions; Donald Berwick, MD, MPP | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 26893 | 89 | | | | | | 0 | http://www.ihi.org | 5/26/2017 2:13:03 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| The Patient and the Anesthesiologist | 2297569 | | 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 | 40432 | 324 | | | | | | 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 |
| One Dose, Fifty Pills (AHRQ) | 2297498 | | 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 | 26106 | 270 | | | | | | 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 |
| Three Ways to Create Psychological Safety in Health Care | 2297951 | | 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 Patient Safety Congress 2022
May 16–18, 2022 | Dallas, TX, USA and Virtual
The IHI Patient Safety Congress, brings together people who are | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo | 26568 | 180 | | | | | | 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 |
| What Is a Culture of Safety? | 2297462 | | 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 | IHI Patient Safety Congress 2022
May 16–18, 2022 | Dallas, TX, USA and Virtual
The IHI Patient Safety Congress, brings together people who are | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 50629 | 290 | | | | | | 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 |
| Why Is Psychological Safety So Important in Health Care? | 2297952 | | 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 Patient Safety Congress 2022
May 16–18, 2022 | Dallas, TX, USA and Virtual
The IHI Patient Safety Congress, brings together people who are | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo | 37068 | 301 | | | | | | 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 |
| 'Enjoy What You Have Left of Your Life' | 2297428 | | 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 | 31356 | 126 | | | | | | 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 |
