| On Being Transparent | 66856 | | You 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 PM | Click 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 52830 | 253 | | | | | | 0 | http://www.ihi.org | 4/11/2014 7:22:33 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 |
| Reconciling Doses (AHRQ) | 66773 | | Faced with a patient who's too confused to remember his medication regimen, a care team administers an overdose of the anticoagulant Warfarin. | 4/7/2014 6:56:50 PM | Learning Objectives: At the end of this activity, you will be able to List the steps involved in medication reconciliation Describe the role of each of the stakeholders in | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 28799 | 120 | | | | | | 0 | http://www.ihi.org | 4/7/2014 6:56:50 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 |
| An Insulin Overdose | 66776 | | In 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 27988 | 182 | | | | | | 0 | http://www.ihi.org | 6/13/2017 2:02:17 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| What Happened to Josie? | 66896 | | In 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 PM | Learning 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 217824 | 1182 | | | | | | 0 | http://www.ihi.org | 5/26/2017 2:45:47 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| An Extended Stay | 66802 | | A 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 PM | Ross 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 90750 | 509 | | | | | | 0 | http://www.ihi.org | 6/13/2017 1:33:07 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 |
| 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 |
| Why Do Errors Happen? How Can We Prevent Them? | 66898 | | Millions of people suffer every year from mistakes in health care. Lucian Leape explains why those mistakes happen — and how to prevent them. | 5/26/2017 2:44:16 PM | Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health
Learning Objectives: After viewing this video, students will be able to | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 30337 | 102 | | | | | | 0 | http://www.ihi.org | 5/26/2017 2:44:16 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
