IHI: PS 102: Study Guide Exam with All
Correct Answers 2026-2027 Updated.
Swiss Cheese Model - Answer of accident causation
idea that harm is caused by a series of systemic failures in the presence of hazard.
the cheese is a level of safety system: usually effective because the holes don't line up
When the hole line up: cause hazards
What are latent condition - Answer defects in the organization of processes and systems
ie. inadequate training, limited resources, poor equipment
these are all often overlooked because of delayed effects
What leads to Active failures? - Answer latent conditions
What are active failures? - Answer error in which effects are felt immediately
Who is the proximal cause of an active failure? What is the real root cause of an active failure? -
Answer proximal cause: doctor, nurse, pharmacist
root cause: error with in the system usually a long time
What do the hole in swish cheese represent? Active or latent failures - Answer both
invariably shows multiple systems failures arising from latent conditions leading to active failure
If a push open door has handles instead of a bar is this an active or latent failure - Answer
latent failure: poor design
active failure: door breaks
A pilot takes off without clearance
unclear communication
, stress from urgency of take off
hierarchical culture: co pilot does speak up
which is active failure? which is latent failure? - Answer 1. A pilot takes off without clearance:
active
2. unclear communication: latent
3.stress from urgency of take off: latent
4.hierarchical culture: co pilot does speak up: latent
What is the relationship between error and harm? - Answer errors will occur without causing
any harm. And sometimes harm will occur when no one can pinpoint an error.
Do all active errors cause harm - Answer no
but they are signs of latent errors
Are system failures the result of an individual? - Answer no but a breakdown in process most
breakdown have been happening just not all of them at once
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
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.
Correct Answers 2026-2027 Updated.
Swiss Cheese Model - Answer of accident causation
idea that harm is caused by a series of systemic failures in the presence of hazard.
the cheese is a level of safety system: usually effective because the holes don't line up
When the hole line up: cause hazards
What are latent condition - Answer defects in the organization of processes and systems
ie. inadequate training, limited resources, poor equipment
these are all often overlooked because of delayed effects
What leads to Active failures? - Answer latent conditions
What are active failures? - Answer error in which effects are felt immediately
Who is the proximal cause of an active failure? What is the real root cause of an active failure? -
Answer proximal cause: doctor, nurse, pharmacist
root cause: error with in the system usually a long time
What do the hole in swish cheese represent? Active or latent failures - Answer both
invariably shows multiple systems failures arising from latent conditions leading to active failure
If a push open door has handles instead of a bar is this an active or latent failure - Answer
latent failure: poor design
active failure: door breaks
A pilot takes off without clearance
unclear communication
, stress from urgency of take off
hierarchical culture: co pilot does speak up
which is active failure? which is latent failure? - Answer 1. A pilot takes off without clearance:
active
2. unclear communication: latent
3.stress from urgency of take off: latent
4.hierarchical culture: co pilot does speak up: latent
What is the relationship between error and harm? - Answer errors will occur without causing
any harm. And sometimes harm will occur when no one can pinpoint an error.
Do all active errors cause harm - Answer no
but they are signs of latent errors
Are system failures the result of an individual? - Answer no but a breakdown in process most
breakdown have been happening just not all of them at once
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
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.
