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/Activities9921110320http://www.ihi.org5/26/2017 2:45:47 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
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/Activities334322970http://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/Activities158261370http://www.ihi.org6/13/2017 2:02:17 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/Activities136982070http://www.ihi.org5/26/2017 2:44:16 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/Activities115291060http://www.ihi.org4/7/2014 6:57:09 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Is the Goal of Reliable Design? (Part 3 of 5)1435432IHI Executive Director Frank Federico explains the goal behind reliable design — and why capability is just as important as reliability. 5/26/2017 1:57:12 PMHow Can You Make Processes Reliable Why Do You Need a Back-Up Plan Bonus: IHI's Whitepaper on Improving the Reliability of Health Care Frank Federico, RPh, IHI Executive Director STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities4468360http://www.ihi.org5/26/2017 1:57:12 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Dealing with Burnout1435270Ana is a second-year resident in a demanding internal medicine residency program. She is generally regarded as one of the most talented residents and has just been elected to the chief resident position for the next year. For several months, however, she has been feeling a significant amount of burnout. Ana’s mood has become low, her energy level has dropped, and she is having difficulty getting out of bed in the morning. She is in the middle of a very demanding ICU (Intensive Care Unit) rotation, during which she is on call every third night, so at first she thinks that it might just be sleep deprivation causing the problem. But she continues to feel increasingly unwell both physically and emotionally. To make matters worse, Ana’s mother was recently diagnosed with breast cancer…9/10/2014 3:07:57 PM Ellis, M.D., Family Physician, Charles River Medical Associates; Morana Lasic, M.D., Clinical Instructor in Anesthesia, Harvard Medical School and Brigham and Women’s Hospital STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies255102250http://www.ihi.org9/10/2014 3:07:57 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/Activities178081400http://www.ihi.org4/7/2014 6:57:41 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/Activities127112010http://www.ihi.org3/6/2019 7:23:28 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Glucose Roller Coaster (AHRQ)1435381A 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 PMLearning 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities11704960http://www.ihi.org4/7/2014 6:57:49 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js

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