IHI PS 102: From Error to Harm Study Guide
Course Overview: This course builds upon PS 101 by exploring how individual errors
can become system failures that lead to patient harm. It focuses on the concept of a
"culture of safety," the importance of effective teamwork and communication, and the
systematic analysis of adverse events to prevent recurrence.
Module 1: Understanding the Culture of Safety
Q1: What is the fundamental principle behind a culture of safety?
ANSWER: ✓ The fundamental principle is that while we cannot change the human
condition (people will make errors), we can change the conditions under which humans
work. Safety is a property of the system, not of the individual.
Q2: How does a "culture of safety" differ from a "culture of blame"?
ANSWER: ✓ A culture of safety focuses on system-level factors that lead to errors and
seeks to redesign systems to prevent future harm. A culture of blame focuses on
individual culpability, discouraging error reporting and learning.
Q3: What are the four key features of a culture of safety, as described by IHI?
ANSWER: ✓
1. Psychological Safety: Staff feel safe speaking up about problems without fear of
reprisal.
2. Acknowledgment of High Risk: Recognition that the work is complex and errors are
inevitable.
3. Reliance on Teamwork and Collaboration: Understanding that safety is a team effort.
4. Organizational Commitment to Resilience: The organization invests in systems and
processes that can absorb errors and prevent harm.
, Q4: What is "psychological safety" and why is it critical in health care?
ANSWER: ✓ Psychological safety is the shared belief that one can speak up with ideas,
questions, concerns, or mistakes without fear of punishment or humiliation. It is critical
because it empowers every team member, regardless of seniority, to identify and report
risks, which is essential for catching errors before they reach the patient.
Q5: What is the primary goal of investigating an adverse event?
ANSWER: ✓ The primary goal is not to assign blame, but to understand the sequence
of events and the underlying system failures that contributed to the outcome, in order
to prevent it from happening again.
Q6: What is "just culture"?
ANSWER: ✓ A just culture is a values-supported model that balances the need for an
open, learning environment with a fair and accountable approach to individual behavior.
It distinguishes between human error (unintentional), at-risk behavior (cutting corners),
and reckless behavior (conscious disregard of risk).
Q7: How does a "just culture" handle a simple human error?
ANSWER: ✓ In a just culture, a simple human error is met with comfort and consolation,
not punishment. The response is to console the individual and look to improve the
system to make it more robust against future errors.
Q8: What is the role of leadership in establishing a culture of safety?
ANSWER: ✓ Leadership must visibly and consistently champion patient safety, allocate
resources for safety initiatives, encourage transparent reporting, and respond to
concerns with a systems-based approach rather than blame.
Q9: What is the first step an organization should take to improve its safety
culture?
Course Overview: This course builds upon PS 101 by exploring how individual errors
can become system failures that lead to patient harm. It focuses on the concept of a
"culture of safety," the importance of effective teamwork and communication, and the
systematic analysis of adverse events to prevent recurrence.
Module 1: Understanding the Culture of Safety
Q1: What is the fundamental principle behind a culture of safety?
ANSWER: ✓ The fundamental principle is that while we cannot change the human
condition (people will make errors), we can change the conditions under which humans
work. Safety is a property of the system, not of the individual.
Q2: How does a "culture of safety" differ from a "culture of blame"?
ANSWER: ✓ A culture of safety focuses on system-level factors that lead to errors and
seeks to redesign systems to prevent future harm. A culture of blame focuses on
individual culpability, discouraging error reporting and learning.
Q3: What are the four key features of a culture of safety, as described by IHI?
ANSWER: ✓
1. Psychological Safety: Staff feel safe speaking up about problems without fear of
reprisal.
2. Acknowledgment of High Risk: Recognition that the work is complex and errors are
inevitable.
3. Reliance on Teamwork and Collaboration: Understanding that safety is a team effort.
4. Organizational Commitment to Resilience: The organization invests in systems and
processes that can absorb errors and prevent harm.
, Q4: What is "psychological safety" and why is it critical in health care?
ANSWER: ✓ Psychological safety is the shared belief that one can speak up with ideas,
questions, concerns, or mistakes without fear of punishment or humiliation. It is critical
because it empowers every team member, regardless of seniority, to identify and report
risks, which is essential for catching errors before they reach the patient.
Q5: What is the primary goal of investigating an adverse event?
ANSWER: ✓ The primary goal is not to assign blame, but to understand the sequence
of events and the underlying system failures that contributed to the outcome, in order
to prevent it from happening again.
Q6: What is "just culture"?
ANSWER: ✓ A just culture is a values-supported model that balances the need for an
open, learning environment with a fair and accountable approach to individual behavior.
It distinguishes between human error (unintentional), at-risk behavior (cutting corners),
and reckless behavior (conscious disregard of risk).
Q7: How does a "just culture" handle a simple human error?
ANSWER: ✓ In a just culture, a simple human error is met with comfort and consolation,
not punishment. The response is to console the individual and look to improve the
system to make it more robust against future errors.
Q8: What is the role of leadership in establishing a culture of safety?
ANSWER: ✓ Leadership must visibly and consistently champion patient safety, allocate
resources for safety initiatives, encourage transparent reporting, and respond to
concerns with a systems-based approach rather than blame.
Q9: What is the first step an organization should take to improve its safety
culture?
