Human Factors1435428Maybe the floor’s wet and slippery. Maybe the cash register is confusingly labeled. Maybe medications are hard to tell apart. Everywhere you look — both in health care and in ordinary retail settings — you can spot circumstances that make it easy for regular people to make mistakes. In this exercise, you’ll go out and analyze everyday situations to determine what human factors issues are at play. You’ll also decide what interventions should be introduced to minimize the opportunities for mistakes.9/18/2015 8:40:55 PM Federico, Content Director, Institute for Healthcare Improvement   Learning Objectives: At the end of this activity, you will be able to Description: Maybe the floor’s wet and STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities321302930http://www.ihi.org9/18/2015 8:40:55 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
An Insulin Overdose1435388In 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities151242170http://www.ihi.org6/13/2017 2:02:17 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Why Is Psychological Safety So Important in Health Care?1435346Why 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 PMCertified Professional in Patient Safety (CPPS) Review Course May 31, 2019 | Princeton, NJ (in-person course) The Certified Professional in Patient STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo132402510http://www.ihi.org8/29/2017 8:37:33 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Misread Label (AHRQ) 1435383An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.4/7/2014 6:57:09 PMCase Study from AHRQ WebM&M; Discussion questions submitted by Andrew Carson-Stevens, Medical Student, Cardiff University, Cardiff, United Kingdom; Jennifer Boehne, PharmD STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities110781270http://www.ihi.org4/7/2014 6:57:09 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Happened to Josie?1435509In 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 PMLearning 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities943798950http://www.ihi.org5/26/2017 2:45:47 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
'Enjoy What You Have Left of Your Life'1435417In 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities176391800http://www.ihi.org5/26/2017 1:50:23 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Why Do Errors Happen? How Can We Prevent Them?1435510Millions 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities128921780http://www.ihi.org5/26/2017 2:44:16 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
The Unfortunate Admission1435275A young woman's lupus flares up, along with a complicating infection. Her providers struggle to coordinate care as her condition deteriorates.3/27/2014 7:46:27 PM was the case study used in the National Forum Clarion Case Study Competition at IHI's 2008 National Forum on Quality Improvement in Health Care The Case: Jane Nagel is an STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies227852430http://www.ihi.org3/27/2014 7:46:27 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Is Reliability? (Part 1 of 5)1435430IHI Executive Director Frank Federico provides an introduction to reliability, including a definition, some examples, and components of IHI’s proven methodology. 3/6/2019 7:23:28 PMHow Can You Make Processes Reliable What Is the Goal of Reliable Design Why Do You Need a Back-Up Plan Bonus: IHI's Whitepaper on Improving the Reliability of Health Care STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities119391690http://www.ihi.org3/6/2019 7:23:28 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Knowing Is Not Enough1435274A healthy 57 year old man underwent a liver donation procedure. He began to manifest some tachycardia late on the second postoperative day. Early on the third post-operative day, he began to hiccup, complained of being nauseated and was pronounced dead later that day.5/24/2017 1:50:08 PMSubmitted by Dr. Paul Batalden, Professor of Pediatrics and of Community & Family Medicine, Dartmouth Medical School Learning Objectives: At the end of this activity, you will be STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies140711420http://www.ihi.org5/24/2017 1:50:08 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js

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