PHAR 464 FINAL QUESTIONS AND ANSWERS 100% CORRECT.
Question 1
Which landmark report, published by the Institute of Medicine in 1999, is credited with
launching the modern patient safety movement?
A) Crossing the Quality Chasm
B) To Err is Human
C) The Belmont Report
D) The Flexner Report
E) Keeping Patients Safe
Correct Answer: B) To Err is Human
Rationale: Published in late 1999, "To Err is Human: Building a Safer Health System"
estimated that up to 98,000 people die each year in U.S. hospitals due to medical errors. It
shifted the focus from blaming individuals to analyzing system failures.
Question 2
According to research published in the British Medical Journal, medical error is estimated to be
which leading cause of death in the United States?
A) First
B) Second
C) Third
D) Fourth
E) Fifth
Correct Answer: C) Third
Rationale: Analysis published by researchers at Johns Hopkins in the BMJ suggested that
medical errors surpass respiratory disease to become the third leading cause of death,
trailing only heart disease and cancer.
Question 3
The "Swiss Cheese Model" of system accidents is a foundational concept in patient safety. What
do the holes in the cheese represent?
A) Individual clinical excellence
B) Perfect institutional policies
C) Vulnerabilities or weaknesses in the systems of care
D) Successfully intercepted errors
E) The final point of patient contact
Correct Answer: C) Vulnerabilities or weaknesses in the systems of care
Rationale: In Reason’s Swiss Cheese Model, each slice represents a layer of defense. The
holes represent latent conditions or active failures. When the holes in many layers line up,
an error reaches the patient.
Question 4
Which of the following quality measures is specifically NOT included in the CMS Hospital-
Acquired Condition (HAC) Reduction Program?
, Page 2
A) Catheter-Associated Urinary Tract Infection (CAUTI) rate
B) Central Line-Associated Bloodstream Infection (CLABSI) rate
C) Surgical Site Infection (SSI) rate
D) Drug-Induced Renal Failure (DIRF) rate
E) Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
Correct Answer: D) Drug-Induced Renal Failure (DIRF) rate
Rationale: The CMS HAC program focuses on specific preventable infections and pressure
ulcers. While drug-induced renal failure is a safety concern, it is not currently one of the
specific metrics used for payment penalties in the HAC program.
Question 5
In the context of error analysis, what is meant by the term "Active Failure"?
A) A policy that was written incorrectly ten years ago
B) An act committed by a person in direct contact with the patient
C) A lack of administrative oversight in the pharmacy department
D) An equipment design flaw that exists in all hospital units
E) The failure of a software update to install correctly
Correct Answer: B) An act committed by a person in direct contact with the patient
Rationale: Active failures are the "sharp end" of an error—the immediate actions (or
inactions) by frontline providers, such as a nurse administering the wrong dose or a
surgeon making an incorrect incision.
Question 6
Which term is synonymous with "error-provoking conditions" that reside in the system's design
or management?
A) Active Failures
B) Near Misses
C) Latent Failures
D) Forcing Functions
E) Affordances
Correct Answer: C) Latent Failures
Rationale: Latent failures are the "blunt end" of the system. They are the hidden "holes" in
the cheese, such as poor staffing, fatigue, confusing equipment labels, or inadequate
training, which lie dormant until they contribute to an active failure.
Question 7
The "Just Culture" model seeks to find a balance between system analysis and what other factor?
A) Financial profitability
B) Individual accountability
C) Regulatory immunity
D) Patient satisfaction scores
E) Length of hospital stay
, Page 3
Correct Answer: B) Individual accountability
Rationale: Just Culture recognizes that while systems should be improved, individuals must
still be held accountable for their choices, particularly if those choices involve reckless
disregard for safety.
Question 8
In a Just Culture system, which of the following is NOT typically classified as one of the three
categories of "unsafe acts" regarding human behavior?
A) Human Error
B) At-Risk Behavior
C) Reckless Behavior
D) Violations
E) Negligence
Correct Answer: D) Violations
Rationale: The standard Just Culture model (as popularized by David Marx) categorizes
behavior into Human Error (unintentional), At-Risk Behavior (choices that increase risk),
and Reckless Behavior (conscious disregard of substantial risk). "Violations" are often
grouped within these, but they are not one of the three primary behavioral categories.
Question 9
What is the appropriate organizational response to a "Human Error" according to the Just Culture
model?
A) Punish the individual to set an example
B) Console the individual
C) Perform a formal reprimand
D) Discharge the employee
E) Require a psychological evaluation
Correct Answer: B) Console the individual
Rationale: Human error is an inadvertent slip or lapse. Because it was unintentional,
punishment does not prevent it. The goal is to console the person (the "second victim") and
fix the system that allowed the error.
Question 10
Which type of behavior warrants a punitive response (discipline/punishment) in the Just Culture
Model?
A) Human Error
B) At-Risk Behavior
C) Recklessness/Negligence
D) A "Near Miss"
E) A technical slip
Correct Answer: C) Recklessness/Negligence
Rationale: Recklessness involves a conscious choice to ignore a substantial and unjustifiable
Question 1
Which landmark report, published by the Institute of Medicine in 1999, is credited with
launching the modern patient safety movement?
A) Crossing the Quality Chasm
B) To Err is Human
C) The Belmont Report
D) The Flexner Report
E) Keeping Patients Safe
Correct Answer: B) To Err is Human
Rationale: Published in late 1999, "To Err is Human: Building a Safer Health System"
estimated that up to 98,000 people die each year in U.S. hospitals due to medical errors. It
shifted the focus from blaming individuals to analyzing system failures.
Question 2
According to research published in the British Medical Journal, medical error is estimated to be
which leading cause of death in the United States?
A) First
B) Second
C) Third
D) Fourth
E) Fifth
Correct Answer: C) Third
Rationale: Analysis published by researchers at Johns Hopkins in the BMJ suggested that
medical errors surpass respiratory disease to become the third leading cause of death,
trailing only heart disease and cancer.
Question 3
The "Swiss Cheese Model" of system accidents is a foundational concept in patient safety. What
do the holes in the cheese represent?
A) Individual clinical excellence
B) Perfect institutional policies
C) Vulnerabilities or weaknesses in the systems of care
D) Successfully intercepted errors
E) The final point of patient contact
Correct Answer: C) Vulnerabilities or weaknesses in the systems of care
Rationale: In Reason’s Swiss Cheese Model, each slice represents a layer of defense. The
holes represent latent conditions or active failures. When the holes in many layers line up,
an error reaches the patient.
Question 4
Which of the following quality measures is specifically NOT included in the CMS Hospital-
Acquired Condition (HAC) Reduction Program?
, Page 2
A) Catheter-Associated Urinary Tract Infection (CAUTI) rate
B) Central Line-Associated Bloodstream Infection (CLABSI) rate
C) Surgical Site Infection (SSI) rate
D) Drug-Induced Renal Failure (DIRF) rate
E) Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
Correct Answer: D) Drug-Induced Renal Failure (DIRF) rate
Rationale: The CMS HAC program focuses on specific preventable infections and pressure
ulcers. While drug-induced renal failure is a safety concern, it is not currently one of the
specific metrics used for payment penalties in the HAC program.
Question 5
In the context of error analysis, what is meant by the term "Active Failure"?
A) A policy that was written incorrectly ten years ago
B) An act committed by a person in direct contact with the patient
C) A lack of administrative oversight in the pharmacy department
D) An equipment design flaw that exists in all hospital units
E) The failure of a software update to install correctly
Correct Answer: B) An act committed by a person in direct contact with the patient
Rationale: Active failures are the "sharp end" of an error—the immediate actions (or
inactions) by frontline providers, such as a nurse administering the wrong dose or a
surgeon making an incorrect incision.
Question 6
Which term is synonymous with "error-provoking conditions" that reside in the system's design
or management?
A) Active Failures
B) Near Misses
C) Latent Failures
D) Forcing Functions
E) Affordances
Correct Answer: C) Latent Failures
Rationale: Latent failures are the "blunt end" of the system. They are the hidden "holes" in
the cheese, such as poor staffing, fatigue, confusing equipment labels, or inadequate
training, which lie dormant until they contribute to an active failure.
Question 7
The "Just Culture" model seeks to find a balance between system analysis and what other factor?
A) Financial profitability
B) Individual accountability
C) Regulatory immunity
D) Patient satisfaction scores
E) Length of hospital stay
, Page 3
Correct Answer: B) Individual accountability
Rationale: Just Culture recognizes that while systems should be improved, individuals must
still be held accountable for their choices, particularly if those choices involve reckless
disregard for safety.
Question 8
In a Just Culture system, which of the following is NOT typically classified as one of the three
categories of "unsafe acts" regarding human behavior?
A) Human Error
B) At-Risk Behavior
C) Reckless Behavior
D) Violations
E) Negligence
Correct Answer: D) Violations
Rationale: The standard Just Culture model (as popularized by David Marx) categorizes
behavior into Human Error (unintentional), At-Risk Behavior (choices that increase risk),
and Reckless Behavior (conscious disregard of substantial risk). "Violations" are often
grouped within these, but they are not one of the three primary behavioral categories.
Question 9
What is the appropriate organizational response to a "Human Error" according to the Just Culture
model?
A) Punish the individual to set an example
B) Console the individual
C) Perform a formal reprimand
D) Discharge the employee
E) Require a psychological evaluation
Correct Answer: B) Console the individual
Rationale: Human error is an inadvertent slip or lapse. Because it was unintentional,
punishment does not prevent it. The goal is to console the person (the "second victim") and
fix the system that allowed the error.
Question 10
Which type of behavior warrants a punitive response (discipline/punishment) in the Just Culture
Model?
A) Human Error
B) At-Risk Behavior
C) Recklessness/Negligence
D) A "Near Miss"
E) A technical slip
Correct Answer: C) Recklessness/Negligence
Rationale: Recklessness involves a conscious choice to ignore a substantial and unjustifiable
