| Learning from Medical Errors (Part 1) | 66863 | | 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 | 49556 | 199 | | | | | | 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) | 66771 | | 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 | 25156 | 209 | | | | | | 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) | 66774 | | 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 | 42048 | 195 | | | | | | 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 |
| Low on the Totem Pole (AHRQ) | 66770 | | 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 | 31930 | 112 | | | | | | 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 |
| Learning from Medical Errors (Part 2) | 66864 | | 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 | 27117 | 84 | | | | | | 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 |
| Three Ways to Create Psychological Safety in Health Care | 66733 | | 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 | Patient Safety Executive Development Program
August 31, 2022 | Boston, MA
With today’s shrinking health care budgets and growing focus on costs, it | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo | 26974 | 147 | | | | | | 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 Can a Zoo Teach Health Care about Patient Safety? | 66666 | | 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 | 51204 | 245 | | | | | | 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 |
| Glucose Roller Coaster (AHRQ) | 66769 | | 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 | 18842 | 38 | | | | | | 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 |
| What Is a Culture of Safety? | 66790 | | 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 | 51254 | 199 | | | | | | 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) | 66772 | | 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 | 26587 | 178 | | | | | | 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 |
