Institute for Healthcare Improvement: Case Studies

	(AHRQ) Code Blue—Where To?
	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.

Rated by Users: User rating

	(AHRQ) Don't Push
	Inappropriate use of IV haloperidol to manage psychosis in an AIDS patient causes polymorphic v-tach ("torsade de pointes"), necessitating a transvenous pacemaker.

This item has not yet been rated

	(AHRQ) Glucose Roller Coaster
	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.

This item has not yet been rated

	(AHRQ) Low on the Totem Pole
	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.

Rated by Users: User rating

	(AHRQ) Misread Label
	An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.

Rated by Users: User rating

	(AHRQ) One Dose, Fifty Pills
	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.

This item has not yet been rated

	(AHRQ) Reconciling Doses
	Faced with a patient who’s too confused to remember his medication regimen, a care team administers an overdose of the anticoagulant Warfarin.

This item has not yet been rated

	(AHRQ) The Wrong Shot: Error Disclosure
	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.

Rated by Users: User rating

	(AHRQ) X-ray Flip
	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.

This item has not yet been rated

	An Insulin Overdose
	In the midst of a high-risk surgery, the senior resident injects 100 times the correct dosage of insulin.

Rated by Users: User rating

	Dealing with Burnout
	Ana is widely regarded as one of the most talented residents in her program—but lately, she can barely get out of bed in the morning. Her patient care is getting sloppy. Making matters worse, her mother was just diagnosed with breast cancer. What should Ana do?

Rated by Users: User rating

Improving Care in Rural Rwanda (Part 1)

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.

Rated by Users: User rating

	Improving Care in Rural Rwanda (Part 2)
	What can we learn from a successful improvement project in rural Rwanda? Discussion questions included.

This item has not yet been rated

	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.

Rated by Users: User rating

	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?

Rated by Users: User rating

	The Unfortunate Admission
	A young woman's lupus flares up, along with a complicating infection. Her providers struggle to coordinate care as her condition deteriorates.

This item has not yet been rated

The Patient and the Anesthesiologist — Part 1: The Incident

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, her anesthesiologist, stepped forward. In Part One of this video case study, you’ll find out what happened in the immediate aftermath of the surgery — and learn about common barriers to the open disclosure of errors in health care.

Rated by Users: User rating

The Patient and the Anesthesiologist — Part 2: The Connection

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, her anesthesiologist, stepped forward. In Part Two of this video case study, you’ll watch Kenney and Van Pelt describe their first meeting after the surgery — an awkward but pivotal experience for both. You’ll also see how they banded together to help other patients and clinicians.

Rated by Users: User rating

	The Patient and the Anesthesiologist — Part 3: The Experts React
	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, her anesthesiologist, stepped forward. In Part Three of this video case study, Kathy Duncan, RN, and Don Berwick, MD, analyze the case.

Rated by Users: User rating