IHI PS 102-105 Final Exam Questions
with All Solved Solutions 2026-2027
Updated.
when an error occurs, which of the following is generally the proper order of prioritization? -
Answer care for the patient, communicate with the patient, report to all appropriate parties,
check the medical record
Why is it important to communicate with the patient about this event? - Answer a and b
Which of the following is true regarding communication about adverse events with patients? -
Answer open communication with patients can assuage caregivers' feelings of guilt.
According to researchers, which of the following is a common reason why caregivers choose not
to communicate when something bad happens? - Answer they fear disapproval
If you are responsible for the initial communication with the patient about the error, which of
the following should you be sure to do? - Answer speak clearly and directly
When an error occurs, which of the following is generally the proper order of prioritization? -
Answer Care for the patient, communicate with the patient, report to all appropriate parties,
check the medical record.
When discussing the event with Mrs. Bernardo, the most appropriate initial comment would be:
- Answer "How is your pain?"
Why is it important for Janice to apologize to Mrs. Bernardo for the delay in her pain
medication? - Answer An apology is needed to maintain provider-patient trust.
Which one of Aaron Lazare's four components of an apology is missing in Janice's apology? -
Answer Reparation
When giving an explanation for why an adverse event happened, it can sometimes be a good
idea to: - Answer Say something like, "There is just no excuse for what happened."
When an adverse event befalls a patient, who are the "second victims" according to Dr. Albert
Wu? - Answer The caregivers involved in the error
,When your supervisor informs you about what happened, you go numb thinking about those six
hours and the cost to the patient. What should ideally happen? - Answer She should speak
calmly with you about what happened and how you're feeling about it.
Why is it important for the organization to offer you help and support at this time? - Answer
Offering support helps prevent depression or decreased job satisfaction.
Based on what you know about the incident, which of the following statements seems to be a
fundamental attribution error? - Answer "The HUC almost killed someone yesterday because
she doesn't pay enough attention."
Which of the following is a support mechanism that might be available to caregivers after
traumatic events? - Answer The Employee Assistance Program
Why should a RCA be conducted by a team rather than by an individual? - Answer
Understanding what led to an error requires diverse perspectives.
The heart of the RCA process is: - Answer Identifying what caused the event.
As the RCA for this case begins, the team struggles with identification of the root causes of the
outcome. They consider the patient's characteristics as well as the work environment. According
to Charles Vincent, what other areas should they consider? - Answer Team factors,
institutional context, and organizational factors
Which of the following is an example of the type of causal statement that this team might
expect to develop? - Answer The patient was unattended for 30 minutes because the nurse
was busy caring for other patients, and this contributed to the outcome.
Which of the following types of interventions is likely to be most effective for improving safety?
- Answer Standardizing processes
At University Hospital, the rate of Clostridium Difficile colitis has doubled during the past year.
After reviewing the data, the hospital's senior leaders conclude that this is due to poor hand
hygiene on the part of the staff, even though they have a clear hand washing policy in place and
don't believe most staff are intentionally disregarding the policy. They decide to start a hand
washing campaign and post signs all over the hospital reminding providers to wash their hands.
What type of error is this intervention best designed to address?
(A) Mistake
(B) Slip
, (C) Lapse
(D) Error of Planning
(E) Violation - Answer (C) lapse
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?
(A) Long work schedule
(B) Fatigue
(C) Inadequate training
(D) None of the above - Answer (A) Long work schedule
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?
(A) Punish the resident and the pharmacist for their careless actions.
(B) Require both the resident and the pharmacist to take additional training.
(C) Develop a system that prevents messy handwriting from causing miscommunication that
leads to error.
(D) Ensure that no prescribing physician is ever tired or distracted. - Answer (C) Develop a
system that prevents messy handwriting from causing miscommunication that leads to error
"Latent errors" are best defined as:
(A) Defects in the design and organization of processes and systems
(B) Errors in patient care that don't ever result in harm and thus go undetected
(C) Mistakes in patient care that providers fail to report due to fear of punishment
(D) Errors in patient care that cause immediate adverse effects - Answer (A) Defects in the
design and organization of processes and systems
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,
with All Solved Solutions 2026-2027
Updated.
when an error occurs, which of the following is generally the proper order of prioritization? -
Answer care for the patient, communicate with the patient, report to all appropriate parties,
check the medical record
Why is it important to communicate with the patient about this event? - Answer a and b
Which of the following is true regarding communication about adverse events with patients? -
Answer open communication with patients can assuage caregivers' feelings of guilt.
According to researchers, which of the following is a common reason why caregivers choose not
to communicate when something bad happens? - Answer they fear disapproval
If you are responsible for the initial communication with the patient about the error, which of
the following should you be sure to do? - Answer speak clearly and directly
When an error occurs, which of the following is generally the proper order of prioritization? -
Answer Care for the patient, communicate with the patient, report to all appropriate parties,
check the medical record.
When discussing the event with Mrs. Bernardo, the most appropriate initial comment would be:
- Answer "How is your pain?"
Why is it important for Janice to apologize to Mrs. Bernardo for the delay in her pain
medication? - Answer An apology is needed to maintain provider-patient trust.
Which one of Aaron Lazare's four components of an apology is missing in Janice's apology? -
Answer Reparation
When giving an explanation for why an adverse event happened, it can sometimes be a good
idea to: - Answer Say something like, "There is just no excuse for what happened."
When an adverse event befalls a patient, who are the "second victims" according to Dr. Albert
Wu? - Answer The caregivers involved in the error
,When your supervisor informs you about what happened, you go numb thinking about those six
hours and the cost to the patient. What should ideally happen? - Answer She should speak
calmly with you about what happened and how you're feeling about it.
Why is it important for the organization to offer you help and support at this time? - Answer
Offering support helps prevent depression or decreased job satisfaction.
Based on what you know about the incident, which of the following statements seems to be a
fundamental attribution error? - Answer "The HUC almost killed someone yesterday because
she doesn't pay enough attention."
Which of the following is a support mechanism that might be available to caregivers after
traumatic events? - Answer The Employee Assistance Program
Why should a RCA be conducted by a team rather than by an individual? - Answer
Understanding what led to an error requires diverse perspectives.
The heart of the RCA process is: - Answer Identifying what caused the event.
As the RCA for this case begins, the team struggles with identification of the root causes of the
outcome. They consider the patient's characteristics as well as the work environment. According
to Charles Vincent, what other areas should they consider? - Answer Team factors,
institutional context, and organizational factors
Which of the following is an example of the type of causal statement that this team might
expect to develop? - Answer The patient was unattended for 30 minutes because the nurse
was busy caring for other patients, and this contributed to the outcome.
Which of the following types of interventions is likely to be most effective for improving safety?
- Answer Standardizing processes
At University Hospital, the rate of Clostridium Difficile colitis has doubled during the past year.
After reviewing the data, the hospital's senior leaders conclude that this is due to poor hand
hygiene on the part of the staff, even though they have a clear hand washing policy in place and
don't believe most staff are intentionally disregarding the policy. They decide to start a hand
washing campaign and post signs all over the hospital reminding providers to wash their hands.
What type of error is this intervention best designed to address?
(A) Mistake
(B) Slip
, (C) Lapse
(D) Error of Planning
(E) Violation - Answer (C) lapse
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?
(A) Long work schedule
(B) Fatigue
(C) Inadequate training
(D) None of the above - Answer (A) Long work schedule
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?
(A) Punish the resident and the pharmacist for their careless actions.
(B) Require both the resident and the pharmacist to take additional training.
(C) Develop a system that prevents messy handwriting from causing miscommunication that
leads to error.
(D) Ensure that no prescribing physician is ever tired or distracted. - Answer (C) Develop a
system that prevents messy handwriting from causing miscommunication that leads to error
"Latent errors" are best defined as:
(A) Defects in the design and organization of processes and systems
(B) Errors in patient care that don't ever result in harm and thus go undetected
(C) Mistakes in patient care that providers fail to report due to fear of punishment
(D) Errors in patient care that cause immediate adverse effects - Answer (A) Defects in the
design and organization of processes and systems
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,
