| The Wrong Shot: Error Disclosure (AHRQ) | 1435386 | | 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 | 23775 | 366 | | | | | | 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 |
| Misread Label (AHRQ) | 1435383 | | 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 | 13669 | 803 | | | | | | 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 |
| What Happened to Josie? | 1435509 | | 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 | 109574 | 1499 | | | | | | 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 |
| Reconciling Doses (AHRQ) | 1435385 | | 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 | 17537 | 276 | | | | | | 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 |
| 'Enjoy What You Have Left of Your Life' | 1435417 | | 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 | 19735 | 282 | | | | | | 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 Do Errors Happen? How Can We Prevent Them? | 1435510 | | 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 | 15448 | 279 | | | | | | 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 |
| On Being Transparent | 1435469 | | 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 | 25693 | 217 | | | | | | 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 |
| An Insulin Overdose | 1435388 | | 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 | 16800 | 160 | | | | | | 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 |
| Don't Push (AHRQ) | 1435380 | | Inappropriate use of IV haloperidol to manage psychosis in an AIDS patient causes polymorphic v-tach ('torsade de pointes'), necessitating a transvenous pacemaker. | 4/7/2014 6:58:08 PM | Learning Objectives: At the end of this activity, you will be able to Describe the delicate balance of effectiveness and safety when it comes to powerful drugs | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 12286 | 95 | | | | | | 0 | http://www.ihi.org | 4/7/2014 6:58:08 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| An Extended Stay | 1435414 | | 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 | 45216 | 459 | | | | | | 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 |
