| Human Factors | 57498 | | 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. | 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_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 4287 | 220 | | | | | | 0 | https://www.ihi.org | 9/18/2015 8:40:55 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| What Happened to Alex? | 57437 | | Alex 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 PM | Leadership for Workforce Well-Being Professional Development Program
Begins April 25–26, 2023 | Online and in person | Boston, MA
High-performing | STS_ListItem_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies | 5782 | 303 | | | | | | 0 | https://www.ihi.org | 7/17/2017 1:55:06 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| What Happened to Josie? | 57579 | | 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. | 5/26/2017 2:45:47 PM | Learning 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_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 22620 | 1410 | | | | | | 0 | https://www.ihi.org | 5/26/2017 2:45:47 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Glucose Roller Coaster (AHRQ) | 57452 | | 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. | 4/7/2014 6:57:49 PM | Learning 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_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 1154 | 90 | | | | | | 0 | https://www.ihi.org | 4/7/2014 6:57:49 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| 'Enjoy What You Have Left of Your Life' | 57487 | | 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. | 5/26/2017 1:50:23 PM | Objectives: At the end of this activity, you will be able to Discuss why it can be challenging for health care providers to care for themselves List at least two examples of unsafe | STS_ListItem_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 1245 | 64 | | | | | | 0 | https://www.ihi.org | 5/26/2017 1:50:23 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Three Ways to Create Psychological Safety in Health Care | 57659 | | How can leaders ― with or without formal authority ― create psychological safety in health care? In a short video, Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, describes three key actions to foster a psychologically safe work environment. | 8/29/2017 8:37:30 PM | Leadership for Workforce Well-Being Professional Development Program
Begins April 25–26, 2023 | Online and in person | Boston, MA
High-performing | STS_ListItem_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo | 3315 | 250 | | | | | | 0 | https://www.ihi.org | 8/29/2017 8:37:30 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Why Is Psychological Safety So Important in Health Care? | 57660 | | Why is psychological safety in health care so important? In a short video, Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, describes four specific outcomes associated with a psychologically safe work environment. | 8/29/2017 8:37:33 PM | Leadership for Workforce Well-Being Professional Development Program
Begins April 25–26, 2023 | Online and in person | Boston, MA
High-performing | STS_ListItem_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo | 5733 | 496 | | | | | | 0 | https://www.ihi.org | 8/29/2017 8:37:33 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Misread Label (AHRQ) | 57454 | | An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity. | 4/7/2014 6:57:09 PM | Case Study from AHRQ
WebM&M; Discussion questions submitted
by Andrew
Carson-Stevens, Medical Student, Cardiff
University, Cardiff, United Kingdom;
Jennifer Boehne, PharmD | STS_ListItem_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 2781 | 122 | | | | | | 0 | https://www.ihi.org | 4/7/2014 6:57:09 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Low on the Totem Pole (AHRQ) | 57453 | | 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. | 4/7/2014 6:57:41 PM | Learning 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_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 2445 | 101 | | | | | | 0 | https://www.ihi.org | 4/7/2014 6:57:41 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| When You Hear Hoofbeats, Don’t Think Zebras | 57514 | | 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. | 5/26/2017 1:59:30 PM | Learning Objectives: At the end of this activity, you will be able to Describe qualities associated with patient-centered care Discuss different ways a provider can respond to | STS_ListItem_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 1646 | 68 | | | | | | 0 | https://www.ihi.org | 5/26/2017 1:59:30 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
