Low on the Totem Pole (AHRQ)57453A 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_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities29041240https://www.ihi.org4/7/2014 6:57:41 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Mutiny57537The 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.4/11/2014 7:51:52 PMClick here to view all of Dr. Paul Griner's case studies Dr. Paul Griner, Professor Emeritus of Medicine at the University of Rochester Learning Objectives: At the end of this STS_ListItem_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities80263370https://www.ihi.org4/11/2014 7:51:52 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Happened to Alex?57437Alex 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 PMCertified Professional in Patient Safety (CPPS) Review Course August 2 – 3, 2023 The Certified Professional in Patient Safety credential (CPPS STS_ListItem_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies80173640https://www.ihi.org7/17/2017 1:55:06 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
An Extended Stay57485A 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_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities119064400https://www.ihi.org6/13/2017 1:33:07 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Confidentiality and Air Force One57488A difficult patient. A difficult decision. The University of Rochester’s Dr. Paul Griner presents the second in a series of case studies.4/11/2014 4:32:13 PMClick here to view all of Dr. Paul Griner's case studies Dr. Paul Griner, Professor Emeritus of Medicine at the University of Rochester Learning Objectives: At the end of this STS_ListItem_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities28251400https://www.ihi.org4/11/2014 4:32:13 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Locked In57523A 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.4/8/2014 8:55:50 PMClick here to view all of Dr. Paul Griner's case studies . Paul Griner, Professor Emeritus of Medicine at the University of Rochester Learning Objectives: At the end of this STS_ListItem_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities30751910https://www.ihi.org4/8/2014 8:55:50 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
The Protective Parent57570During 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.”5/26/2017 2:42:39 PMClick here to view all of Dr. Paul Griner's case studies . Paul Griner, Professor Emeritus of Medicine at the University of Rochester Learning Objectives: At the end of this STS_ListItem_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities40562270https://www.ihi.org5/26/2017 2:42:39 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
An Insulin Overdose57459In 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_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities29322080https://www.ihi.org6/13/2017 2:02:17 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
What Happened to Josie?57579In 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. 5/26/2017 2:45:47 PMLearning Objectives: At the end of this activity, you will be able to Discuss factors that contribute to avoidable patient harm, even at renowned facilities If you plan to be a STS_ListItem_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities295989870https://www.ihi.org5/26/2017 2:45:47 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
The Patient and the Anesthesiologist57541Linda 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_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities43822500https://www.ihi.org10/30/2018 4:00:05 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js

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