Human Factors57498Maybe 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_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities23312340https://www.ihi.org9/18/2015 8:40:55 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 PMIHI Forum 2022 December 4–7, 2022 | Orlando, FL, USA December 13–15, 2022 | Online The IHI Forum is a four-day conference that has been the home of STS_ListItem_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies26263210https://www.ihi.org7/17/2017 1:55:06 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Dealing with Burnout57434Ana 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…9/10/2014 3:07:57 PM Ellis, M.D., Family Physician, Charles River Medical Associates; Morana Lasic, M.D., Clinical Instructor in Anesthesia, Harvard Medical School and Brigham and Women’s Hospital STS_ListItem_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies128989920https://www.ihi.org9/10/2014 3:07:57 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/Activities1216611860https://www.ihi.org5/26/2017 2:45:47 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
X-ray Flip (AHRQ)57458A 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_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities992840https://www.ihi.org4/7/2014 6:56:41 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Misread Label (AHRQ) 57454An 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_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities16771140https://www.ihi.org4/7/2014 6:57:09 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
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/Activities13922940https://www.ihi.org4/7/2014 6:57:41 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/Activities14461580https://www.ihi.org10/30/2018 4:00:05 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Knowing Is Not Enough57438A 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_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies855510https://www.ihi.org5/24/2017 1:50:08 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js
Glucose Roller Coaster (AHRQ)57452A 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.4/7/2014 6:57:49 PMLearning Objectives: At the end of this activity, you will be able to Explain why good communication is critical to patient safety Description: A woman hospitalized for congestive STS_ListItem_PublishingPageshttps://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities486520https://www.ihi.org4/7/2014 6:57:49 PMhtmlFalseaspx1616~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js

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