IHI PS 102 UPDATED ACTUAL QUESTIONS AND CORRECT
ANSWERS
Question:
1. Referring to the video on the previous page, which of the following factors do you think contributed to
the Tenerife plane crash?
Answer:
- Foggy weather that limited visibility
-Stress and distraction on the part of the pilot
- Time pressure due to crew duty hours
- Language differences
-Miscommunication between the two planes and the control tower
-Problems with the radio transmission
-A hierarchical culture that limited the junior crew's willingness to speak up
Question:
2. Referring to the video on the previous page, which of the following factors do you think did not
contributed to the Tenerife plane crash?
Answer:
- Incompetent staff
- Mechanical problems
Question:
3. Which of the following would be an effective solution to help prevent the Tenerife disaster from
happening again?
Answer:
- Train people about safety culture to help them speak up in a hierarchical system.
- Standardize communication about clearance for take off.
Question:
4. Which of the following factors makes health care dangerous to patients and providers?
Answer:
All of the above
Question:
5. Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose
levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for
"units"), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that's ten
times stronger than the patient needs. Which of the following is a latent unsafe condition in the system that
contributes to the resident's error?
Answer:
Long work schedule
, Question:
6. Two women — one named Camilla Tyler, the other named Camilla Taylor — arrive at a particularly
busy emergency department at about the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an
antibiotic. The doctor orders the medications, but mixes up the patients when filling out the order sheets.
The pharmacist dispenses the medications as ordered, and the nurse administers an antibiotic to Ms. Tyler
and a sedative to Ms. Taylor. What is one of the latent errors in this scenario?
Answer:
The forms are completed by hand at the same time for different patients.
Question:
7. Two women — one named Camilla Tyler, the other named Camilla Taylor — arrive at a particularly
busy emergency department at about the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an
antibiotic. The doctor orders the medications, but mixes up the patients when filling out the order sheets.
The pharmacist dispenses the medications as ordered, and the nurse administers an antibiotic to Ms. Tyler
and a sedative to Ms. Taylor. What is the active error in this scenario?
Answer:
The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
Question:
8. "Latent errors" are best defined as:
Answer:
Defects in the design and organization of processes and systems.
Question:
9. Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose
levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for
"units"), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that's ten
times stronger than the patient needs. To prevent this problem from happening again, which of the
following would be the best course of action?
Answer:
Develop a system that prevents messy handwriting from causing miscommunication that leads to error.
Question:
10. The term "medical error" is slightly misleading because the patterns of errors that occur in health care
are no different from those that occur in any other setting when we are distracted, in a hurry, or just plain
forgetful. Consider the following scenario: A nurse, Anila, oversleeps and is running late to work. As she
rushes through her morning routine, she forgets she promised to call her mother to confirm plans for later
in the day.Anila makes it out the door in record time and decides to drive toward the highway, thinking it
will be faster than her usual route to the hospital — only to find traffic is backed up for miles!At last, Anila
makes it to work. As she hurries inside, she finally remembers to call her mom. But in her hurry, she
accidentally calls her boyfriend instead. "Three errors and I haven't even seen a patient yet," she thinks.
Which type(s) of error did Anila make? (Select all that apply.)
Answer:
- Slip
- Lapse
- Mistake
ANSWERS
Question:
1. Referring to the video on the previous page, which of the following factors do you think contributed to
the Tenerife plane crash?
Answer:
- Foggy weather that limited visibility
-Stress and distraction on the part of the pilot
- Time pressure due to crew duty hours
- Language differences
-Miscommunication between the two planes and the control tower
-Problems with the radio transmission
-A hierarchical culture that limited the junior crew's willingness to speak up
Question:
2. Referring to the video on the previous page, which of the following factors do you think did not
contributed to the Tenerife plane crash?
Answer:
- Incompetent staff
- Mechanical problems
Question:
3. Which of the following would be an effective solution to help prevent the Tenerife disaster from
happening again?
Answer:
- Train people about safety culture to help them speak up in a hierarchical system.
- Standardize communication about clearance for take off.
Question:
4. Which of the following factors makes health care dangerous to patients and providers?
Answer:
All of the above
Question:
5. Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose
levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for
"units"), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that's ten
times stronger than the patient needs. Which of the following is a latent unsafe condition in the system that
contributes to the resident's error?
Answer:
Long work schedule
, Question:
6. Two women — one named Camilla Tyler, the other named Camilla Taylor — arrive at a particularly
busy emergency department at about the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an
antibiotic. The doctor orders the medications, but mixes up the patients when filling out the order sheets.
The pharmacist dispenses the medications as ordered, and the nurse administers an antibiotic to Ms. Tyler
and a sedative to Ms. Taylor. What is one of the latent errors in this scenario?
Answer:
The forms are completed by hand at the same time for different patients.
Question:
7. Two women — one named Camilla Tyler, the other named Camilla Taylor — arrive at a particularly
busy emergency department at about the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an
antibiotic. The doctor orders the medications, but mixes up the patients when filling out the order sheets.
The pharmacist dispenses the medications as ordered, and the nurse administers an antibiotic to Ms. Tyler
and a sedative to Ms. Taylor. What is the active error in this scenario?
Answer:
The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
Question:
8. "Latent errors" are best defined as:
Answer:
Defects in the design and organization of processes and systems.
Question:
9. Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose
levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for
"units"), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that's ten
times stronger than the patient needs. To prevent this problem from happening again, which of the
following would be the best course of action?
Answer:
Develop a system that prevents messy handwriting from causing miscommunication that leads to error.
Question:
10. The term "medical error" is slightly misleading because the patterns of errors that occur in health care
are no different from those that occur in any other setting when we are distracted, in a hurry, or just plain
forgetful. Consider the following scenario: A nurse, Anila, oversleeps and is running late to work. As she
rushes through her morning routine, she forgets she promised to call her mother to confirm plans for later
in the day.Anila makes it out the door in record time and decides to drive toward the highway, thinking it
will be faster than her usual route to the hospital — only to find traffic is backed up for miles!At last, Anila
makes it to work. As she hurries inside, she finally remembers to call her mom. But in her hurry, she
accidentally calls her boyfriend instead. "Three errors and I haven't even seen a patient yet," she thinks.
Which type(s) of error did Anila make? (Select all that apply.)
Answer:
- Slip
- Lapse
- Mistake
