Activities

Browse by Course:
 
​Below are activities that focus on key concepts taught in the IHI Open School courses. These patient stories, exercises, videos, case studies, audio clips, and other resources are designed for individual or group engagement. We encourage you to use these activities in parallel with our courses to expand your knowledge and skills, and to share your passion for quality, safety, and improvement with your interprofessional colleagues.

first last

  • Human Factors
    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.
  • Reconciling Doses (AHRQ)
    Faced with a patient who's too confused to remember his medication regimen, a care team administers an overdose of the anticoagulant Warfarin.
  • How Can Disruptive Behavior Be Harmful?
    Physician Kevin Stewart explains how he accidentally hurt a patient when he was trying to avoid a confrontation with his foul-tempered supervisor. He offers advice for people who find themselves on the receiving end of disrespectful behavior.
  • Learning from Medical Errors (Part 1)
    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.
  • Learning from Medical Errors (Part 2)
    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.
  • What Happened to Josie?
    In 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.
  • Why Do Errors Happen? How Can We Prevent Them?
    Millions of people suffer every year from mistakes in health care. Lucian Leape explains why those mistakes happen — and how to prevent them.
  • When You Hear Hoofbeats, Don’t Think Zebras
    In a new patient story, IHI Open School Academic Advisor Dr. James Moses introduces us to Lauren, an 18-year-old female who endured a painful journey through the health care system. One morning during her first semester of college in Boston, Lauren woke up with soreness in the side of her face. Several months – and a misdiagnosis later – the pain only got worse.
  • 'Enjoy What You Have Left of Your Life'
    In a new patient story, you’ll hear the story of a nurse named Christiane who becomes a patient after she is diagnosed with an inoperable brain tumor in the midst of her career. As you follow Christiane’s story, you’ll be prompted to stop along the way to consider a number of questions about her care and challenging transition from provider to patient. When you get to the end of the story, you’ll hear from Christiane and get her perspective on the experience.
  • Noah’s Story: Are You Listening?
    Our newest patient story follows the care experience of four-year-old Noah and his mom, Tanya. A surgery, a series of miscommunications, and an early discharge from the hospital contribute to an adverse event that changes the family’s life forever.
 

 

first last

  • Human Factors
    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.
  • Glucose Roller Coaster (AHRQ)
    A 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.
  • Low on the Totem Pole (AHRQ)
    A 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.
  • One Dose, Fifty Pills (AHRQ)
    Told to give a patient one gram of steroids, an intern mistakenly orders fifty 20-mg pills. Although a pharmacist questions the order, the intern insists that the medication be given as ordered.
  • Reconciling Doses (AHRQ)
    Faced with a patient who's too confused to remember his medication regimen, a care team administers an overdose of the anticoagulant Warfarin.
  • X-ray Flip (AHRQ)
    A 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.
  • An Insulin Overdose
    In the midst of a high-risk surgery, the senior resident injects 100 times the correct dosage of insulin.
  • How Can We Define “Quality” in Health Care?
    In this video, IHI’s Former CEO Don Berwick describes a 2001 report by the Institute of Medicine, Crossing the Quality Chasm, that laid the foundation for health care reform in the United States and spread around the world.
  • Learning from Medical Errors (Part 1)
    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.
  • Learning from Medical Errors (Part 2)
    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.
  • The Patient and the Anesthesiologist
    Linda 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.
  • What Happened to Josie?
    In 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.
  • Why Do Errors Happen? How Can We Prevent Them?
    Millions of people suffer every year from mistakes in health care. Lucian Leape explains why those mistakes happen — and how to prevent them.
  • 'Enjoy What You Have Left of Your Life'
    In a new patient story, you’ll hear the story of a nurse named Christiane who becomes a patient after she is diagnosed with an inoperable brain tumor in the midst of her career. As you follow Christiane’s story, you’ll be prompted to stop along the way to consider a number of questions about her care and challenging transition from provider to patient. When you get to the end of the story, you’ll hear from Christiane and get her perspective on the experience.
  • 'Sue, Can You Smile?'
    In 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.
  • An Extended Stay
    A 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.
​ ​​Back to top

 
 

first last

  • Human Factors
    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.
  • Don't Push (AHRQ)
    Inappropriate use of IV haloperidol to manage psychosis in an AIDS patient causes polymorphic v-tach ('torsade de pointes'), necessitating a transvenous pacemaker.
  • Misread Label (AHRQ)
    An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.
  • Reconciling Doses (AHRQ)
    Faced with a patient who's too confused to remember his medication regimen, a care team administers an overdose of the anticoagulant Warfarin.
  • X-ray Flip (AHRQ)
    A 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.
  • An Insulin Overdose
    In the midst of a high-risk surgery, the senior resident injects 100 times the correct dosage of insulin.
  • Knowing Is Not Enough
    A 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.
  • Dealing with Burnout
    Ana 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…
  • How Can Disruptive Behavior Be Harmful?
    Physician Kevin Stewart explains how he accidentally hurt a patient when he was trying to avoid a confrontation with his foul-tempered supervisor. He offers advice for people who find themselves on the receiving end of disrespectful behavior.
  • How Can You Identify and Confront Workarounds?
    What are workarounds? Why are they bad? How do we avoid them? MIT senior lecturer and IHI Senior Fellow Steve Spear explains.
  • Why Do Errors Happen? How Can We Prevent Them?
    Millions of people suffer every year from mistakes in health care. Lucian Leape explains why those mistakes happen — and how to prevent them.
  • Jill's Medication Crisis
    A 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.
  • 'Enjoy What You Have Left of Your Life'
    In a new patient story, you’ll hear the story of a nurse named Christiane who becomes a patient after she is diagnosed with an inoperable brain tumor in the midst of her career. As you follow Christiane’s story, you’ll be prompted to stop along the way to consider a number of questions about her care and challenging transition from provider to patient. When you get to the end of the story, you’ll hear from Christiane and get her perspective on the experience.
  • An Extended Stay
    A 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.
 
 

first last

  • Don't Push (AHRQ)
    Inappropriate use of IV haloperidol to manage psychosis in an AIDS patient causes polymorphic v-tach ('torsade de pointes'), necessitating a transvenous pacemaker.
  • Glucose Roller Coaster (AHRQ)
    A 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.
  • Misread Label (AHRQ)
    An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.
  • One Dose, Fifty Pills (AHRQ)
    Told to give a patient one gram of steroids, an intern mistakenly orders fifty 20-mg pills. Although a pharmacist questions the order, the intern insists that the medication be given as ordered.
  • Code Blue - Where To? (AHRQ)
    A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team do not know where the service is located, and when the team arrives, they find their equipment to be incompatible with the leads on the patient.
  • Knowing Is Not Enough
    A 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.
  • How Do You Apologize After a Medical Error?
    When you make a mistake that affects a patient, what should you say? Should you apologize, or will that put you at greater risk of being sued? Lucian Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, describes how to talk with patients and families after a mistake has occurred.
  • Disruptive Behavior: A Slap on the Hand
    When you’re rude and disrespectful to your co-workers, you put your patients at risk. In this video, former nurse Jill Duncan recalls watching a senior nurse bully a medical resident. She explains why this behavior happens, and how you should respond if you’re on the receiving end.
  • Disruptive Behavior: The Arterial Stick
    A resident tells a medical student to do a blood gas on a patient. The student says, “I don’t know how.” The resident is annoyed – and he says something that he’ll regret for years. Physician Ron Wyatt reflects on what he said (and wishes he had said) to the student.
  • The Patient and the Anesthesiologist
    Linda 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.
  • What Happened to Josie?
    In 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.
  • What Is Lauren's List?
    Sally Sampson talks about the creation of Lauren's List, four simple rules her young daughter had for clinicians.
  • The Protective Parent
    During a 50-year career in medicine, Dr. Paul Griner accumulated hundreds of patient stories. Most of his stories – including this case study "The Protective Parent" - are from the 1950s and 1960s, prior to what we now refer to as “modern medicine.”
  • How Can Health Care Workers Inspire Patients?
    Gilbert Salinas, Director of Patient-Centered Care at a rehabilitation center in California, talks about the compassionate health care professionals that inspired his career path.
  • Confidentiality and Air Force One
    A difficult patient. A difficult decision. The University of Rochester’s Dr. Paul Griner presents the second in a series of case studies.
  • Locked In
    A cancer diagnosis leads to tears and heartache. But is it correct? Dr. Paul Griner, Professor Emeritus of Medicine at the University of Rochester, presents the third in a series of case studies for the IHI Open School.
  • When You Hear Hoofbeats, Don’t Think Zebras
    In a new patient story, IHI Open School Academic Advisor Dr. James Moses introduces us to Lauren, an 18-year-old female who endured a painful journey through the health care system. One morning during her first semester of college in Boston, Lauren woke up with soreness in the side of her face. Several months – and a misdiagnosis later – the pain only got worse.
  • Mutiny
    The behavior of a superior starts to put your patients at risk. What would you do? The University of Rochester’s Dr. Paul Griner presents the final installment in a series of case studies for the IHI Open School.
  • A Wild (and Costly) Goose Chase
    In a new patient story, you’ll hear from Rani, a patient who visits several different health care providers in search of a diagnosis. As you follow Rani’s story, you’ll be prompted to stop along the way to consider a number of questions about miscommunication, cost, and the patient perspective. When you get to the end of the story, you’ll hear from Rani as she looks back on the experience seven years later.
  • Why Does Trevor Recommend Type 1 Diabetes?
    In this video, patient Trevor Torres shares four things. He gives two reasons why he’d recommend type 1 diabetes to anyone and two pieces of practical advice for health care providers.

 
 

first last

  • Code Blue - Where To? (AHRQ)
    A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team do not know where the service is located, and when the team arrives, they find their equipment to be incompatible with the leads on the patient.
  • The Crowded Clinic
    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?
  • Knowing Is Not Enough
    A 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.
  • How Can You Identify and Confront Workarounds?
    What are workarounds? Why are they bad? How do we avoid them? MIT senior lecturer and IHI Senior Fellow Steve Spear explains.
​​Back to top
 
 

PS 105: Responding to Adverse Events​

first last

  • Don't Push (AHRQ)
    Inappropriate use of IV haloperidol to manage psychosis in an AIDS patient causes polymorphic v-tach ('torsade de pointes'), necessitating a transvenous pacemaker.
  • Misread Label (AHRQ)
    An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.
  • The Wrong Shot: Error Disclosure (AHRQ)
    A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers.
  • An Insulin Overdose
    In the midst of a high-risk surgery, the senior resident injects 100 times the correct dosage of insulin.
  • How Do You Apologize After a Medical Error?
    When you make a mistake that affects a patient, what should you say? Should you apologize, or will that put you at greater risk of being sued? Lucian Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, describes how to talk with patients and families after a mistake has occurred.
  • Learning from Medical Errors (Part 1)
    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.
  • Learning from Medical Errors (Part 2)
    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.
  • The Patient and the Anesthesiologist
    Linda 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.
  • An Interview with IHI's Hannah Humpal
    IHI 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.
  • When You Hear Hoofbeats, Don’t Think Zebras
    In a new patient story, IHI Open School Academic Advisor Dr. James Moses introduces us to Lauren, an 18-year-old female who endured a painful journey through the health care system. One morning during her first semester of college in Boston, Lauren woke up with soreness in the side of her face. Several months – and a misdiagnosis later – the pain only got worse.
  • On Being Transparent
    You are the CEO and a patient in your hospital dies from a medication error. What do you do next? The University of Rochester’s Dr. Paul Griner presents the fourth in a series of case studies.
  • 'Sue, Can You Smile?'
    In 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.
  • An Extended Stay
    A 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.
 
 
​​PS 202: Building a Culture of Safety

first last

  • Glucose Roller Coaster (AHRQ)
    A 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.
  • Low on the Totem Pole (AHRQ)
    A 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.
  • One Dose, Fifty Pills (AHRQ)
    Told to give a patient one gram of steroids, an intern mistakenly orders fifty 20-mg pills. Although a pharmacist questions the order, the intern insists that the medication be given as ordered.
  • The Wrong Shot: Error Disclosure (AHRQ)
    A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers.
  • Dealing with Burnout
    Ana 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…
  • How Do You Apologize After a Medical Error?
    When you make a mistake that affects a patient, what should you say? Should you apologize, or will that put you at greater risk of being sued? Lucian Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, describes how to talk with patients and families after a mistake has occurred.
  • Disruptive Behavior: A Slap on the Hand
    When you’re rude and disrespectful to your co-workers, you put your patients at risk. In this video, former nurse Jill Duncan recalls watching a senior nurse bully a medical resident. She explains why this behavior happens, and how you should respond if you’re on the receiving end.
  • How Can Disruptive Behavior Be Harmful?
    Physician Kevin Stewart explains how he accidentally hurt a patient when he was trying to avoid a confrontation with his foul-tempered supervisor. He offers advice for people who find themselves on the receiving end of disrespectful behavior.
  • Disruptive Behavior: The Arterial Stick
    A resident tells a medical student to do a blood gas on a patient. The student says, “I don’t know how.” The resident is annoyed – and he says something that he’ll regret for years. Physician Ron Wyatt reflects on what he said (and wishes he had said) to the student.
  • The Patient and the Anesthesiologist
    Linda 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.
  • How Can Primary Care Be More Fulfilling?
    Primary care suffers from a lot of problems, says physician executive Douglas Eby. Clinicians often have to work too quickly to get to know their patients, which makes for unfulfilling work and an ineffective care model. At Anchorage-based Alaska Native Medical Center, however, things are different.
  • Confidentiality and Air Force One
    A difficult patient. A difficult decision. The University of Rochester’s Dr. Paul Griner presents the second in a series of case studies.
  • Locked In
    A cancer diagnosis leads to tears and heartache. But is it correct? Dr. Paul Griner, Professor Emeritus of Medicine at the University of Rochester, presents the third in a series of case studies for the IHI Open School.
  • Mutiny
    The behavior of a superior starts to put your patients at risk. What would you do? The University of Rochester’s Dr. Paul Griner presents the final installment in a series of case studies for the IHI Open School.
  • Noah’s Story: Are You Listening?
    Our newest patient story follows the care experience of four-year-old Noah and his mom, Tanya. A surgery, a series of miscommunications, and an early discharge from the hospital contribute to an adverse event that changes the family’s life forever.


 
PS 203: Partnering to Heal: Teaming Up Against Healthcare-Associated Infections​

first last

  • Low on the Totem Pole (AHRQ)
    A 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.
​​Back to top

 
 
QI 101: Introduction to Health Care Improvement

first last

  • X-ray Flip (AHRQ)
    A 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.
  • How Can We Define “Quality” in Health Care?
    In this video, IHI’s Former CEO Don Berwick describes a 2001 report by the Institute of Medicine, Crossing the Quality Chasm, that laid the foundation for health care reform in the United States and spread around the world.
  • What Are the Biggest Challenges Facing Your Health System?
    What's the single biggest challenge the US health care system will face within the next five to ten years? We put the question to a doctor, a nurse, a professor, a student, a hospital CEO, and a patient.
  • Advanced Case Study
    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.
  • What's the Role of Social Media in Health Care?
    Paul Levy, the former CEO and President of Beth Israel Deaconess Medical Center in Boston, writes a blog called Not Running a Hospital that gets about 10,000 visitors every day. In this two-part video series, we learn how Levy got involved in blogging, how his blog promoted transparency at his hospital, and tips for success in social media.
  • On Being Transparent
    You are the CEO and a patient in your hospital dies from a medication error. What do you do next? The University of Rochester’s Dr. Paul Griner presents the fourth in a series of case studies.
  • Noah’s Story: Are You Listening?
    Our newest patient story follows the care experience of four-year-old Noah and his mom, Tanya. A surgery, a series of miscommunications, and an early discharge from the hospital contribute to an adverse event that changes the family’s life forever.
 

 
QI 102: How to Improve with the Model for Improvement

first last

  • Improving Care in Rural Rwanda
    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.
  • Advanced Case Study
    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.
  • What's the Role of Social Media in Health Care?
    Paul Levy, the former CEO and President of Beth Israel Deaconess Medical Center in Boston, writes a blog called Not Running a Hospital that gets about 10,000 visitors every day. In this two-part video series, we learn how Levy got involved in blogging, how his blog promoted transparency at his hospital, and tips for success in social media.
​​Back to top
 
 

first last

  • Advanced Case Study
    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.
​​​Back to top

 

 

first last

  • Improving Care in Rural Rwanda
    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.
​​Back to top
 
 

first last

  • Improving Care in Rural Rwanda
    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.
  • Locked In
    A cancer diagnosis leads to tears and heartache. But is it correct? Dr. Paul Griner, Professor Emeritus of Medicine at the University of Rochester, presents the third in a series of case studies for the IHI Open School.
  • A Wild (and Costly) Goose Chase
    In a new patient story, you’ll hear from Rani, a patient who visits several different health care providers in search of a diagnosis. As you follow Rani’s story, you’ll be prompted to stop along the way to consider a number of questions about miscommunication, cost, and the patient perspective. When you get to the end of the story, you’ll hear from Rani as she looks back on the experience seven years later.
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  • Advanced Case Study
    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.
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first last

  • Advanced Case Study
    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.
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  • How Does a Hospital Involve Patients in Design?
    Take a look inside Cincinnati Children’s Hospital as its clinicians learn how to make the valuable — but challenging — transition to a truly patient-centered environment.
  • How Can Primary Care Be More Fulfilling?
    Primary care suffers from a lot of problems, says physician executive Douglas Eby. Clinicians often have to work too quickly to get to know their patients, which makes for unfulfilling work and an ineffective care model. At Anchorage-based Alaska Native Medical Center, however, things are different.
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  • The Crowded Clinic
    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?
  • Improving Care in Rural Rwanda
    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.
  • How Can We Define “Quality” in Health Care?
    In this video, IHI’s Former CEO Don Berwick describes a 2001 report by the Institute of Medicine, Crossing the Quality Chasm, that laid the foundation for health care reform in the United States and spread around the world.
  • How Does a Hospital Involve Patients in Design?
    Take a look inside Cincinnati Children’s Hospital as its clinicians learn how to make the valuable — but challenging — transition to a truly patient-centered environment.
  • How Can Primary Care Be More Fulfilling?
    Primary care suffers from a lot of problems, says physician executive Douglas Eby. Clinicians often have to work too quickly to get to know their patients, which makes for unfulfilling work and an ineffective care model. At Anchorage-based Alaska Native Medical Center, however, things are different.
  • How Can Health Care Workers Inspire Patients?
    Gilbert Salinas, Director of Patient-Centered Care at a rehabilitation center in California, talks about the compassionate health care professionals that inspired his career path.
  • Why Should Clinicians Focus on Population Health?
    Holly Oh, a pediatrician at The Dimock Center in Boston, looks back on a memorable patient encounter from almost a decade ago.
  • What Is Shared Decision Making?
    Victor Montori, MD, MSc, a Professor of Medicine at the Mayo Clinic in Rochester, Minnesota, is pioneering the concept of shared decision making. What is shared decision making and how can it improve care for patients? Dr. Montori, a special interest keynote speaker at this year’s IHI National Forum in December, explains.
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first last

  • Improving Care in Rural Rwanda
    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.
  • Disruptive Behavior: A Slap on the Hand
    When you’re rude and disrespectful to your co-workers, you put your patients at risk. In this video, former nurse Jill Duncan recalls watching a senior nurse bully a medical resident. She explains why this behavior happens, and how you should respond if you’re on the receiving end.
  • Disruptive Behavior: The Arterial Stick
    A resident tells a medical student to do a blood gas on a patient. The student says, “I don’t know how.” The resident is annoyed – and he says something that he’ll regret for years. Physician Ron Wyatt reflects on what he said (and wishes he had said) to the student.
  • Confidentiality and Air Force One
    A difficult patient. A difficult decision. The University of Rochester’s Dr. Paul Griner presents the second in a series of case studies.
  • What's the Role of Social Media in Health Care?
    Paul Levy, the former CEO and President of Beth Israel Deaconess Medical Center in Boston, writes a blog called Not Running a Hospital that gets about 10,000 visitors every day. In this two-part video series, we learn how Levy got involved in blogging, how his blog promoted transparency at his hospital, and tips for success in social media.
  • On Being Transparent
    You are the CEO and a patient in your hospital dies from a medication error. What do you do next? The University of Rochester’s Dr. Paul Griner presents the fourth in a series of case studies.
  • Why Should Clinicians Focus on Population Health?
    Holly Oh, a pediatrician at The Dimock Center in Boston, looks back on a memorable patient encounter from almost a decade ago.
  • Mutiny
    The behavior of a superior starts to put your patients at risk. What would you do? The University of Rochester’s Dr. Paul Griner presents the final installment in a series of case studies for the IHI Open School.
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  • The Wrong Shot: Error Disclosure (AHRQ)
    A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers.
  • The Crowded Clinic
    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?
  • How Can We Improve Care for Older Patients?
    Clinical Nurse Specialist Connie Davis says her career caring for the elderly has been “an amazing gift.” Learn how practicing patient-centered care with seniors can enrich both your life and their health outcomes.
  • How Does a Hospital Involve Patients in Design?
    Take a look inside Cincinnati Children’s Hospital as its clinicians learn how to make the valuable — but challenging — transition to a truly patient-centered environment.
  • What Is Lauren's List?
    Sally Sampson talks about the creation of Lauren's List, four simple rules her young daughter had for clinicians.
  • An Interview with IHI's Hannah Humpal
    IHI 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.
  • Jill's Medication Crisis
    A 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.
  • The Protective Parent
    During a 50-year career in medicine, Dr. Paul Griner accumulated hundreds of patient stories. Most of his stories – including this case study "The Protective Parent" - are from the 1950s and 1960s, prior to what we now refer to as “modern medicine.”
  • How Can Health Care Workers Inspire Patients?
    Gilbert Salinas, Director of Patient-Centered Care at a rehabilitation center in California, talks about the compassionate health care professionals that inspired his career path.
  • Locked In
    A cancer diagnosis leads to tears and heartache. But is it correct? Dr. Paul Griner, Professor Emeritus of Medicine at the University of Rochester, presents the third in a series of case studies for the IHI Open School.
  • When You Hear Hoofbeats, Don’t Think Zebras
    In a new patient story, IHI Open School Academic Advisor Dr. James Moses introduces us to Lauren, an 18-year-old female who endured a painful journey through the health care system. One morning during her first semester of college in Boston, Lauren woke up with soreness in the side of her face. Several months – and a misdiagnosis later – the pain only got worse.
  • Why Should Clinicians Focus on Population Health?
    Holly Oh, a pediatrician at The Dimock Center in Boston, looks back on a memorable patient encounter from almost a decade ago.
  • What Is Shared Decision Making?
    Victor Montori, MD, MSc, a Professor of Medicine at the Mayo Clinic in Rochester, Minnesota, is pioneering the concept of shared decision making. What is shared decision making and how can it improve care for patients? Dr. Montori, a special interest keynote speaker at this year’s IHI National Forum in December, explains.
  • 'Enjoy What You Have Left of Your Life'
    In a new patient story, you’ll hear the story of a nurse named Christiane who becomes a patient after she is diagnosed with an inoperable brain tumor in the midst of her career. As you follow Christiane’s story, you’ll be prompted to stop along the way to consider a number of questions about her care and challenging transition from provider to patient. When you get to the end of the story, you’ll hear from Christiane and get her perspective on the experience.
  • A Wild (and Costly) Goose Chase
    In a new patient story, you’ll hear from Rani, a patient who visits several different health care providers in search of a diagnosis. As you follow Rani’s story, you’ll be prompted to stop along the way to consider a number of questions about miscommunication, cost, and the patient perspective. When you get to the end of the story, you’ll hear from Rani as she looks back on the experience seven years later.
  • Why Does Trevor Recommend Type 1 Diabetes?
    In this video, patient Trevor Torres shares four things. He gives two reasons why he’d recommend type 1 diabetes to anyone and two pieces of practical advice for health care providers.
  • 'Sue, Can You Smile?'
    In 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.
  • Noah’s Story: Are You Listening?
    Our newest patient story follows the care experience of four-year-old Noah and his mom, Tanya. A surgery, a series of miscommunications, and an early discharge from the hospital contribute to an adverse event that changes the family’s life forever.
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PFC 201: A Guide to Shadowing: Seeing Care Through the Eyes of Patients and Famil​ies 
 

first last

  • The Crowded Clinic
    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?
  • An Interview with IHI's Hannah Humpal
    IHI 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.
  • What Is Shared Decision Making?
    Victor Montori, MD, MSc, a Professor of Medicine at the Mayo Clinic in Rochester, Minnesota, is pioneering the concept of shared decision making. What is shared decision making and how can it improve care for patients? Dr. Montori, a special interest keynote speaker at this year’s IHI National Forum in December, explains.
  • How Can Shadowing Make Care More Patient-Centered?
    In a short video interview, Anthony M. DiGioia, MD, pioneer in patient- and family-centered care, explains why it’s time to think like your patients.


 

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  • Code Blue - Where To? (AHRQ)
    A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team do not know where the service is located, and when the team arrives, they find their equipment to be incompatible with the leads on the patient.
  • How Can We Improve Care for Older Patients?
    Clinical Nurse Specialist Connie Davis says her career caring for the elderly has been “an amazing gift.” Learn how practicing patient-centered care with seniors can enrich both your life and their health outcomes.
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  • An Extended Stay
    A 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.
  • How Can We Define “Quality” in Health Care?
    In this video, IHI’s Former CEO Don Berwick describes a 2001 report by the Institute of Medicine, Crossing the Quality Chasm, that laid the foundation for health care reform in the United States and spread around the world.
  • When You Hear Hoofbeats, Don’t Think Zebras
    In a new patient story, IHI Open School Academic Advisor Dr. James Moses introduces us to Lauren, an 18-year-old female who endured a painful journey through the health care system. One morning during her first semester of college in Boston, Lauren woke up with soreness in the side of her face. Several months – and a misdiagnosis later – the pain only got worse.
 
 
 

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  • What Are the Biggest Challenges Facing Your Health System?
    What's the single biggest challenge the US health care system will face within the next five to ten years? We put the question to a doctor, a nurse, a professor, a student, a hospital CEO, and a patient.
  • How Can You Identify and Confront Workarounds?
    What are workarounds? Why are they bad? How do we avoid them? MIT senior lecturer and IHI Senior Fellow Steve Spear explains.
  • A Wild (and Costly) Goose Chase
    In a new patient story, you’ll hear from Rani, a patient who visits several different health care providers in search of a diagnosis. As you follow Rani’s story, you’ll be prompted to stop along the way to consider a number of questions about miscommunication, cost, and the patient perspective. When you get to the end of the story, you’ll hear from Rani as she looks back on the experience seven years later.
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