| Human Factors | 66815 | | Maybe 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 62299 | 186 | | | | | | 0 | http://www.ihi.org | 9/18/2015 8:40:55 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Advanced Case Study | 66766 | | Between Sept. 30th and Oct. 14th, 2010, students and residents all over the world gathered in interprofessional teams and analyzed a complex incident that resulted in patient harm. Selected teams presented their work to IHI faculty during a series of live webinars in October. | 6/8/2017 6:09:00 PM | Karyn Baum, MD, MSEd, Associate Professor of Medicine, University of Minnesota Reviewers:
Barbara Balik, RN, EdD, Senior Faculty Member, IHI; Jonathan Finkelstein, MD, MPH | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 81719 | 212 | | | | | | 0 | http://www.ihi.org | 6/8/2017 6:09:00 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| The Crowded Clinic | 66886 | | Patients aren't showing up for their appointments at the community health center. The results? Delays, overcrowding, and mounting frustration for everyone. Can this clinic be saved? | 6/10/2019 3:01:26 PM | Kate Ellis, MD, Family Physician, Charles River Medical Associates; Morana Lasic, MD, Clinical Instructor in Anesthesia, Harvard Medical School and Brigham and Women’s Hospital | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 47125 | 134 | | | | | | 0 | http://www.ihi.org | 6/10/2019 3:01:26 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| What Is Reliability? (Part 1 of 5) | 66817 | | IHI Executive Director Frank Federico provides an introduction to reliability, including a definition, some examples, and components of IHI’s proven methodology. | 8/16/2021 2:16:07 PM | How 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 26772 | 162 | | | | | | 0 | http://www.ihi.org | 8/16/2021 2:16:07 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Learning from Medical Errors (Part 1) | 66863 | | A patient suffers horrible burns. An operation takes twice as long as it should. A child dies from internal bleeding. All because a doctor, a nurse, or another care provider made a mistake. In this video, prominent clinicians describe the errors that still haunt them today — and point out ways those errors could have been prevented. | 5/26/2017 2:12:52 PM | Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health; Kathy Duncan, RN, 5 Million Lives Campaign Faculty, Institute for Healthcare Improvement | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 49556 | 199 | | | | | | 0 | http://www.ihi.org | 5/26/2017 2:12:52 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Improving Care in Rural Rwanda | 66830 | | When Dr. Patrick Lee and his teammates began their quality improvement work in Kirehe, Rwanda, last year, the staff at the local hospital was taking vital signs properly less than half the time. Today, the staff does that task properly 95% of the time. Substantial resource and infrastructure inputs, combined with dedicated Rwandan partners and simple quality improvement tools, have dramatically improved staff morale and the quality of care in Kirehe. | 5/26/2017 1:59:20 PM | Patrick Lee, MD, Partners In Health, Volunteer Clinical Mentor, Newton-Wellesley Hospital, Hospitalist Physician, Harvard Medical School, Clinical Instructor in Medicine | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 33293 | 185 | | | | | | 0 | http://www.ihi.org | 5/26/2017 1:59:20 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| What Is the Goal of Reliable Design? (Part 3 of 5) | 66819 | | IHI Executive Director Frank Federico explains the goal behind reliable design — and why capability is just as important as reliability. | 8/16/2021 2:18:20 PM | How 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_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 8875 | 26 | | | | | | 0 | http://www.ihi.org | 8/16/2021 2:18:20 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 |
| How Long Should a PDSA Cycle Last? | 66868 | | You know PDSAs are rapid tests of change. But what, exactly, is a good length of time for a Plan-Do-Study-Act test cycle? Learn from Lloyd Provost, co-author of the Improvement Guide. | 5/26/2017 2:14:06 PM | Patient Safety Executive Development Program
August 31, 2022 | Boston, MA
With today’s shrinking health care budgets and growing focus on costs, it | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 14726 | 45 | | | | | | 0 | http://www.ihi.org | 5/26/2017 2:14:06 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Learning from Medical Errors (Part 2) | 66864 | | A baby falls gravely ill after a botched blood transfusion. A student nearly commits a medication error. A patient dies after a clumsy surgery. In this video, current and former clinicians (including IHI’s Former CEO Don Berwick) describe the errors that still haunt them today — and point out ways those errors could have been prevented. | 5/26/2017 2:13:03 PM | Frankel, MD, Director of Patient Safety, Partners Healthcare; Kevin Knoblock, Student, MSN/Nurse Practitioner Program, MGH Institute of Health Professions; Donald Berwick, MD, MPP | STS_ListItem_PublishingPages | | | http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 27117 | 84 | | | | | | 0 | http://www.ihi.org | 5/26/2017 2:13:03 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
