Human Factors66815Maybe 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/Activities622991860http://www.ihi.org9/18/2015 8:40:55 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Advanced Case Study66766Between 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 PMKaryn 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities817192120http://www.ihi.org6/8/2017 6:09:00 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
The Crowded Clinic66886Patients 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 PMKate 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities471251340http://www.ihi.org6/10/2019 3:01:26 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Is Reliability? (Part 1 of 5)66817IHI 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 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/Activities267721620http://www.ihi.org8/16/2021 2:16:07 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Learning from Medical Errors (Part 1)66863A 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities495561990http://www.ihi.org5/26/2017 2:12:52 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Improving Care in Rural Rwanda 66830When 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 PMPatrick Lee, MD, Partners In Health, Volunteer Clinical Mentor, Newton-Wellesley Hospital, Hospitalist Physician, Harvard Medical School, Clinical Instructor in Medicine STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities332931850http://www.ihi.org5/26/2017 1:59:20 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Is the Goal of Reliable Design? (Part 3 of 5)66819IHI 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 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/Activities8875260http://www.ihi.org8/16/2021 2:18:20 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Misread Label (AHRQ) 66771An 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/Activities251562090http://www.ihi.org4/7/2014 6:57:09 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
How Long Should a PDSA Cycle Last?66868You 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 PMPatient Safety Executive Development Program August 31, 2022 | Boston, MA With today’s shrinking health care budgets and growing focus on costs, it STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities14726450http://www.ihi.org5/26/2017 2:14:06 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Learning from Medical Errors (Part 2)66864A 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_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities27117840http://www.ihi.org5/26/2017 2:13:03 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js

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