PHAR 464 Final Exam Questions and
Answers (Latest 2026)
what are active failures? - Correct Answers ✅1. "sharp end
of the error"
2. slips, lapses, mistakes, violations
what are latent failures? - Correct Answers ✅1. "blunt end
of errors"
2. fundamental vulnerabilities or conditions that contribute to
active failures (error provoking conditions)
3. may have dormant stage where they are not leading to
errors
what is just culture? - Correct Answers ✅1. don't punish
when someone is involved in an error that could affect
"anybody" in the same position
2. punish gross negligence
what does the Just Culture Model focus on? - Correct
Answers ✅1. focuses on latent system failures
2. add layers of swiss cheese
3. close holes in swiss cheese
how to manage at-risk behaviors? - Correct Answers ✅1.
remove rewards for risky behavior
2. create incentives for safe behavior
3. increase mindfulness
, PHAR 464 Final Exam Questions and
Answers (Latest 2026)
what is Root Cause Analysis (RCA)? - Correct Answers ✅a
systematic process utilized to determine the PRIMARY cause
of system failures
what is a root cause? - Correct Answers ✅any identified
reason in the sequence of events that, if prevented, will stop
recurrence of the particular event
-there must be a clear cause and effect
what is a sentinel event? - Correct Answers ✅a patient
safety event (not related to natural course of pt's illness) that
reaches a patient and results in harm
What is failure mode and effects analysis (FMEA)? - Correct
Answers ✅problem-solving tool used to analyze a process
or system to identify possible modes of failure and potential
consequences of those failures
criteria for an effective RCA process - Correct Answers ✅1.
define problem and significance
2. delineate known causal relationships that combined to
cause problem
3. establish causal relationships between root cause(s) and
problem
4. present evidence
Answers (Latest 2026)
what are active failures? - Correct Answers ✅1. "sharp end
of the error"
2. slips, lapses, mistakes, violations
what are latent failures? - Correct Answers ✅1. "blunt end
of errors"
2. fundamental vulnerabilities or conditions that contribute to
active failures (error provoking conditions)
3. may have dormant stage where they are not leading to
errors
what is just culture? - Correct Answers ✅1. don't punish
when someone is involved in an error that could affect
"anybody" in the same position
2. punish gross negligence
what does the Just Culture Model focus on? - Correct
Answers ✅1. focuses on latent system failures
2. add layers of swiss cheese
3. close holes in swiss cheese
how to manage at-risk behaviors? - Correct Answers ✅1.
remove rewards for risky behavior
2. create incentives for safe behavior
3. increase mindfulness
, PHAR 464 Final Exam Questions and
Answers (Latest 2026)
what is Root Cause Analysis (RCA)? - Correct Answers ✅a
systematic process utilized to determine the PRIMARY cause
of system failures
what is a root cause? - Correct Answers ✅any identified
reason in the sequence of events that, if prevented, will stop
recurrence of the particular event
-there must be a clear cause and effect
what is a sentinel event? - Correct Answers ✅a patient
safety event (not related to natural course of pt's illness) that
reaches a patient and results in harm
What is failure mode and effects analysis (FMEA)? - Correct
Answers ✅problem-solving tool used to analyze a process
or system to identify possible modes of failure and potential
consequences of those failures
criteria for an effective RCA process - Correct Answers ✅1.
define problem and significance
2. delineate known causal relationships that combined to
cause problem
3. establish causal relationships between root cause(s) and
problem
4. present evidence
