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/Activities348034360http://www.ihi.org9/18/2015 8:40:55 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/Activities125464250http://www.ihi.org4/7/2014 6:57:09 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/Activities148203870http://www.ihi.org5/26/2017 2:44:16 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Jill's Medication Crisis1435416A patient story activity – The Medication – that describes a patient’s journey to get her anticonvulsant medications. The breakdown in continuity of care and communication is an ideal learning opportunity for students and professionals. 4/11/2014 7:59:00 PMLearning Objectives: At the end of this activity, you will be able to Identify two instances when communication broke down in the continuum of care As you read Jill’s story, take STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities85621640http://www.ihi.org4/11/2014 7:59:00 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/Activities144062810http://www.ihi.org4/7/2014 6:56:41 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Reconciling Doses (AHRQ)1435385Faced with a patient who's too confused to remember his medication regimen, a care team administers an overdose of the anticoagulant Warfarin.4/7/2014 6:56:50 PMLearning Objectives: At the end of this activity, you will be able to List the steps involved in medication reconciliation Describe the role of each of the stakeholders in STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities170322580http://www.ihi.org4/7/2014 6:56:50 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
An Extended Stay1435414A 64-year-old man with a number of health issues comes to the hospital because he is having trouble breathing. The care team helps resolve the issue, but forgets a standard treatment that causes unnecessary harm to the patient. A subsequent medication error makes the situation worse, leading a stay that is much longer than anticipated. 6/13/2017 1:33:07 PMRoss Hilliard, MD, IHI Open School Northeast Regional Chapter Leader Learning Objectives: At the end of this activity, you will be able to Explain how system failures can lead to STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities442597060http://www.ihi.org6/13/2017 1:33:07 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/Activities165022040http://www.ihi.org6/13/2017 2:02:17 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
How Can You Make Processes Reliable? (Part 2 of 5)1435431IHI Executive Director Frank Federico discusses steps you can take to make your processes more reliable. 5/26/2017 1:56:27 PMWhat 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 Frank Federico, RPh, IHI Executive Director STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities6287900http://www.ihi.org5/26/2017 1:56:27 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 PMFrom Hospital to Home: Using Quality Improvement to Optimize Discharge Efficiency Begins October 8, 2019 | IHI Virtual Expedition Patient Safety Executive Development Program STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies315124470http://www.ihi.org7/17/2017 1:55:06 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js

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