| 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 | 5305 | 187 | | | | | | 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 | Certified Professional in Patient Safety (CPPS) Review Course
August 2 – 3, 2023
The Certified Professional in Patient Safety credential (CPPS | STS_ListItem_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies | 7851 | 421 | | | | | | 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 |
| An Extended Stay | 57485 | | 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. | 6/13/2017 1:33:07 PM | Ross 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_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 11676 | 437 | | | | | | 0 | https://www.ihi.org | 6/13/2017 1:33:07 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| An Insulin Overdose | 57459 | | In 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_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 2834 | 196 | | | | | | 0 | https://www.ihi.org | 6/13/2017 2:02:17 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 | 3349 | 123 | | | | | | 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 |
| Why Do Errors Happen? How Can We Prevent Them? | 57581 | | Millions of people suffer every year from mistakes in health care. Lucian Leape explains why those mistakes happen — and how to prevent them. | 5/26/2017 2:44:16 PM | Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health
Learning Objectives: After viewing this video, students will be able to | STS_ListItem_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 4258 | 100 | | | | | | 0 | https://www.ihi.org | 5/26/2017 2:44:16 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Knowing Is Not Enough | 57438 | | 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. | 5/24/2017 1:50:08 PM | Submitted 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_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies | 1754 | 79 | | | | | | 0 | https://www.ihi.org | 5/24/2017 1:50:08 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 | 2205 | 61 | | | | | | 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 |
| X-ray Flip (AHRQ) | 57458 | | 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. | 4/7/2014 6:56:41 PM | Case 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_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 2101 | 73 | | | | | | 0 | https://www.ihi.org | 4/7/2014 6:56:41 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
| Reconciling Doses (AHRQ) | 57456 | | Faced with a patient who's too confused to remember his medication regimen, a care team administers an overdose of the anticoagulant Warfarin. | 4/7/2014 6:56:50 PM | Learning Objectives: At the end of this activity, you will be able to List the steps involved in medication reconciliation Describe the role of each of the stakeholders in | STS_ListItem_PublishingPages | | | https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities | 1374 | 55 | | | | | | 0 | https://www.ihi.org | 4/7/2014 6:56:50 PM | html | False | | aspx | | 16 | 16 | ~sitecollection/_catalogs/masterpage/Display Templates/Search/Item_WebPage.js |
