PS 102: From error to harm-Test
Questions and 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? - Answer long work schedule
To prevent this problem from happening again, which of the following would be the best course
of action? - Answer Develop a system that prevents messy handwriting from causing
miscommunication that leads to error.
"Latent errors" are best defined as: - 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? - Answer The nurse administers an antibiotic to Ms.
Tyler and a sedative to Ms. Taylor.
What is one of the latent errors in this scenario? - Answer The forms are completed by hand at
the same time for different patients.
According to James Reason, by definition an "unsafe act" always includes: - Answer 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
family physicians in the clinic, who agrees. At the end of the day, as she is working on her
documentation, she realizes she never told Mr. Drummond to increase his insulin dose.
Questions and 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? - Answer long work schedule
To prevent this problem from happening again, which of the following would be the best course
of action? - Answer Develop a system that prevents messy handwriting from causing
miscommunication that leads to error.
"Latent errors" are best defined as: - 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? - Answer The nurse administers an antibiotic to Ms.
Tyler and a sedative to Ms. Taylor.
What is one of the latent errors in this scenario? - Answer The forms are completed by hand at
the same time for different patients.
According to James Reason, by definition an "unsafe act" always includes: - Answer 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
family physicians in the clinic, who agrees. At the end of the day, as she is working on her
documentation, she realizes she never told Mr. Drummond to increase his insulin dose.
