PS 102: From Error to Harm-Final Exam
with Detailed Answers 2026-2027
Updated.
Referring to the video on the previous page, which of the following factors do you think
contributed to the Tenerife plane crash? (Select all that apply)
Incompetent staff
Problems with the radio transmission
Time pressure due to crew duty hours
Miscommunication between the two planes and the control tower
Stress and distraction on the part of the pilot
Mechanical problems
Foggy weather that limited visibility
A hierarchical culture that limited the junior crew's willingness to speak up
Language differences - Answer Problems with the radio transmission
Time pressure due to crew duty hours
Miscommunication between the two planes and the control tower
Stress and distraction on the part of the pilot
Foggy weather that limited visibility
A hierarchical culture that limited the junior crew's willingness to speak up
Language differences
(all but Incompetent staff and Mechanical problems)
Which of the following would be an effective solution to help prevent the Tenerife disaster from
happening again? (select all that apply)
Fire the individuals who failed to deliver the message that the runway wasn't clear for take off.
Standardize communication about clearance for take off.
Stop flying on foggy days.
Train people about safety culture to help them speak up in a hierarchical system.
Hire more competent pilots and flight crews. - Answer Standardize communication about
clearance for take off.
Train people about safety culture to help them speak up in a hierarchical system.
, 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. Develop a system that prevents messy handwriting from causing miscommunication that
leads to error.
C. Ensure that no prescribing physician is ever tired or distracted.
D. Require both the resident and the pharmacist to take additional training. - Answer B.
Develop a system that prevents messy handwriting from causing miscommunication that leads
to error.
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 two patients in this case have very similar names.
D. The forms are completed by hand at the same time for different patients. - Answer D. The
forms are completed by hand at the same time for different patients.
Which of the following factors makes health care dangerous to patients and providers?
A. Powerful drugs
B. Complicated procedures
C. Patients who require complex care
D. All of the above - Answer D. All of the above
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.
with Detailed Answers 2026-2027
Updated.
Referring to the video on the previous page, which of the following factors do you think
contributed to the Tenerife plane crash? (Select all that apply)
Incompetent staff
Problems with the radio transmission
Time pressure due to crew duty hours
Miscommunication between the two planes and the control tower
Stress and distraction on the part of the pilot
Mechanical problems
Foggy weather that limited visibility
A hierarchical culture that limited the junior crew's willingness to speak up
Language differences - Answer Problems with the radio transmission
Time pressure due to crew duty hours
Miscommunication between the two planes and the control tower
Stress and distraction on the part of the pilot
Foggy weather that limited visibility
A hierarchical culture that limited the junior crew's willingness to speak up
Language differences
(all but Incompetent staff and Mechanical problems)
Which of the following would be an effective solution to help prevent the Tenerife disaster from
happening again? (select all that apply)
Fire the individuals who failed to deliver the message that the runway wasn't clear for take off.
Standardize communication about clearance for take off.
Stop flying on foggy days.
Train people about safety culture to help them speak up in a hierarchical system.
Hire more competent pilots and flight crews. - Answer Standardize communication about
clearance for take off.
Train people about safety culture to help them speak up in a hierarchical system.
, 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. Develop a system that prevents messy handwriting from causing miscommunication that
leads to error.
C. Ensure that no prescribing physician is ever tired or distracted.
D. Require both the resident and the pharmacist to take additional training. - Answer B.
Develop a system that prevents messy handwriting from causing miscommunication that leads
to error.
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 two patients in this case have very similar names.
D. The forms are completed by hand at the same time for different patients. - Answer D. The
forms are completed by hand at the same time for different patients.
Which of the following factors makes health care dangerous to patients and providers?
A. Powerful drugs
B. Complicated procedures
C. Patients who require complex care
D. All of the above - Answer D. All of the above
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.
