IHI PS 102 Final Exam Questions and All
Actual Answers 2026-2027 Updated.
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 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,
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?
(A) The forms are completed by hand at the same time for different patients.
(B) The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
(C) The emergency department is particularly busy.
(D) The pharmacist doesn't notice that the order sheets are incorrectly filled out - Answer (B)
The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
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?
(A) The emergency department is particularly busy.
(B) The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
(C) The forms are completed by hand at the same time for different patients.
(D) The two patients in this case have very similar names. - Answer (C) The forms are
completed by hand at the same time for different patients.
"Knowledge-based errors" are best defined as:
(A) Errors in the design and organization of processes and systems
(B) Errors in problem-solving and decision making
(C) Errors in patient care that don't result in injury and thus go undetected
(D) Errors in automatic functioning - Answer (B) Errors in problem-solving and decision
making
According to James Reason, by definition an "unsafe act" always includes:
(A) A potential hazard
(B) Harm to one or more patients
(C) One or more mistakes
(D) All of the above - Answer (A) A potential hazard
Anita, a nurse practitioner, is seeing Mr. Drummond in clinic. Mr. Drummond is a 57-year-old
man with diabetes and chronic kidney disease. Having kept up on the literature, Anita is aware
that tightly controlling his diabetes can slow the progression of his renal disease. She discusses
her plan to increase his dose of glargine (long-acting insulin) by 12 units per day with one of the
Actual Answers 2026-2027 Updated.
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 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,
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?
(A) The forms are completed by hand at the same time for different patients.
(B) The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
(C) The emergency department is particularly busy.
(D) The pharmacist doesn't notice that the order sheets are incorrectly filled out - Answer (B)
The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
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?
(A) The emergency department is particularly busy.
(B) The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.
(C) The forms are completed by hand at the same time for different patients.
(D) The two patients in this case have very similar names. - Answer (C) The forms are
completed by hand at the same time for different patients.
"Knowledge-based errors" are best defined as:
(A) Errors in the design and organization of processes and systems
(B) Errors in problem-solving and decision making
(C) Errors in patient care that don't result in injury and thus go undetected
(D) Errors in automatic functioning - Answer (B) Errors in problem-solving and decision
making
According to James Reason, by definition an "unsafe act" always includes:
(A) A potential hazard
(B) Harm to one or more patients
(C) One or more mistakes
(D) All of the above - Answer (A) A potential hazard
Anita, a nurse practitioner, is seeing Mr. Drummond in clinic. Mr. Drummond is a 57-year-old
man with diabetes and chronic kidney disease. Having kept up on the literature, Anita is aware
that tightly controlling his diabetes can slow the progression of his renal disease. She discusses
her plan to increase his dose of glargine (long-acting insulin) by 12 units per day with one of the
