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/Activities379513700http://www.ihi.org9/18/2015 8:40:55 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Low on the Totem Pole (AHRQ)1435382A 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 PMLearning 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities202813020http://www.ihi.org4/7/2014 6:57:41 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
X-ray Flip (AHRQ)1435387A patient comes to the emergency department with a pneumothorax on his left side. His radiograph is mistakenly labeled backwards, and the resident assigned to the patient wrongly places a chest tube on the right side.4/7/2014 6:56:41 PMCase Study from AHRQ WebM&M    Learning Objectives: At the end of this activity, you will be able to Explain why certain wrong-site errors occur in health care settings STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities161281600http://www.ihi.org4/7/2014 6:56:41 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/Activities11901813270http://www.ihi.org5/26/2017 2:45:47 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Is a Culture of Safety?1435402Dr. 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 PMDavid 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities347156030http://www.ihi.org5/24/2017 5:29:43 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Why Is Reducing Harm — Not Just Error — Important to Patient Safety?1435401Dr. David Bates, a world renowned patient safety expert, explains why the field of patient safety has shifted from reducing error to also encompass efforts to reduce harm.1/25/2018 2:47:37 PMDavid 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities296133000http://www.ihi.org1/25/2018 2:47:37 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
When You Hear Hoofbeats, Don’t Think Zebras1435444In a new patient story, IHI Open School Academic Advisor Dr. James Moses introduces us to Lauren, an 18-year-old female who endured a painful journey through the health care system. One morning during her first semester of college in Boston, Lauren woke up with soreness in the side of her face. Several months – and a misdiagnosis later – the pain only got worse. 5/26/2017 1:59:30 PMLearning Objectives: At the end of this activity, you will be able to Describe qualities associated with patient-centered care Discuss different ways a provider can respond to STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities102821270http://www.ihi.org5/26/2017 1:59:30 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
How Can Disruptive Behavior Be Harmful?1435422Physician Kevin Stewart explains how he accidentally hurt a patient when he was trying to avoid a confrontation with his foul-tempered supervisor. He offers advice for people who find themselves on the receiving end of disrespectful behavior.5/26/2017 1:50:32 PM Stewart, MB, FRCP; Medical Director, Winchester Hospital, UK; Health Foundation/IHI Quality Improvement Fellow Learning Objectives: At the end of this activity, you will be able STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities6854760http://www.ihi.org5/26/2017 1:50:32 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/CaseStudies271032650http://www.ihi.org3/27/2014 7:46:27 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Happened to Alex?1435273Alex James was a runner, like his dad. One day, he collapsed during a run and was hospitalized for five days. He went through lots of tests, but was given a clean bill of health. Then, a month later, he collapsed again, fell into a deep coma, and died. His father wanted to know — what had gone wrong? Dr. John James, a retired toxicologist at NASA, tells the story of how he uncovered the cause of his son’s death and became a patient safety advocate.7/17/2017 1:55:06 PMFinding and Creating Joy in Work March 11, 2020 | IHI Online Course with Coaching To help reverse the worrying trend of burnout among health care STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies344352320http://www.ihi.org7/17/2017 1:55:06 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js

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