IHI PS 102 questions with complete solutions

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 correct answer: (A) Long work schedule 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. correct 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 pr