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/Activities156031680http://www.ihi.org4/7/2014 6:56:41 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/Activities197511660http://www.ihi.org4/7/2014 6:57:41 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/Activities174001240http://www.ihi.org6/13/2017 2:02:17 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
An Interview with IHI's Hannah Humpal1435439IHI staff member Hannah Humpal had knee surgery a few years ago. Her surgeon told her she had a 1 in 1,000,000 chance of rejecting the tissue during the procedure. As fate would have it, she was the 1. Hannah shares her story of a rocky journey through the health care system – and how she would have done things differently today.5/26/2017 1:58:32 PMLearning Objectives: At the end of this activity, you will be able to Discuss how a health care professional’s attitude and behavior can affect a patient’s care journey STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities4543480http://www.ihi.org5/26/2017 1:58:32 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
The Patient and the Anesthesiologist1435471Linda Kenney went into the hospital for an ankle replacement. She came out with a host of complications resulting from a mistake that no one was willing to admit. Until Rick van Pelt, MD, her anesthesiologist, stepped forward. In this three-part video case study, you’ll find out what happened in the immediate aftermath of the surgery, watch Kenney and van Pelt describe their first meeting after the surgery, and watch Kathy Duncan, RN, and Don Berwick, MD, analyze the case.10/30/2018 4:00:05 PMDonald Berwick, MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement; Kathy Duncan, RN, Faculty, Institute for Healthcare Improvement; Linda Kenney STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities234852580http://www.ihi.org10/30/2018 4:00:05 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Knowing Is Not Enough1435274A healthy 57 year old man underwent a liver donation procedure. He began to manifest some tachycardia late on the second postoperative day. Early on the third post-operative day, he began to hiccup, complained of being nauseated and was pronounced dead later that day.5/24/2017 1:50:08 PMSubmitted by Dr. Paul Batalden, Professor of Pediatrics and of Community & Family Medicine, Dartmouth Medical School Learning Objectives: At the end of this activity, you will be STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies16207760http://www.ihi.org5/24/2017 1:50:08 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
'Sue, Can You Smile?'1435493In a new patient story, you’ll meet Sue, a nurse who undergoes several operations to remove a mass behind her ear, resulting in an adverse event. As you follow Sue’s story, you’ll be prompted to stop along the way to consider a number of questions about making mistakes, communication after adverse events, and the patient, family, and caregiver perspectives. When you get to the end of the story, you’ll hear from Sue and her surgeon, Dr. Rae, as they look back on the experience nearly seven years later.5/26/2017 2:39:58 PMLearning Objectives: At the end of this activity, you will be able to Explain the importance of keeping patients’ families informed about the care experience When you get to the end STS_ListItem_PublishingPageshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities6641510http://www.ihi.org5/26/2017 2:39:58 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js

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