Patient Safety: IHI PS 101 – Introduction to Patient Safety – 2026 – Study and
Training Guide
According to WHO, in developed countries worldwide, what is the approximate likelihood that a
hospitalized patient will be harmed while receiving care? - correct answer ✔✔ 10%
According to WHO, in developed countries up to 10 percent of hospital patients may be harmed
while receiving care.
Since the publication of To Err Is Human in 1999, the health care industry overall has seen which
of the following improvements? - correct answer ✔✔ Wider awareness that preventable errors
are a problem
More than a decade after the publication of To Err Is Human, there is now wide recognition
throughout health care that the number of errors is way too high. Although this awareness has
not yet led to consistently lower rates of preventable medical error, progress is being made.
Health care organizations have begun to realize and accept that most errors cannot be linked to
the performance of individuals, but rather to the systems in which they function.
Safety has been called a "dynamic non-event" because when humans are in a potentially
hazardous environment: - correct answer ✔✔ It takes significant work to ensure nothing bad
happens
The best answer is it takes significant work to ensure nothing bad happens. When things go
right in a potentially hazardous environment, nothing bad happens. But in order for this "non-
event" of nothing going wrong to occur, a lot of things must be done right. Thus, safety has been
described as a "dynamic non-event."
To prevent this type of error from recurring in this unit, which of the following is MOST
important? - correct answer ✔✔ An improved culture of safety and teamwork
, Had there been a culture of safety fostering better teamwork, this error may well have been
prevented. In this case, when James asked Maria for help, she made him feel bad instead of
being a team player. In this type of environment, James may be reluctant to ask for help, even if
he is more closely supervised. We can generally assume that health care providers do not want
to harm their patients, so the threat of punishment is not the best way to prevent mistakes.
Although errors may occur when there is no recognized best practice, in the case of IV fluid
replacement, clear recommendations do exist.
Who is likely to be negatively affected by this medical error? - correct answer ✔✔ All of the
above
The best answer is all of the above. Patients and families are not the only ones affected when a
medical error occurs. In this case, James is likely to be devastated, and Maria may be affected as
well. Some providers even leave their profession after committing errors leading to a death.
One hospital CEO insists on including performance data in the hospital's annual report. "We do
very well on most measures, except for one or two, but we put those in anyway," she says. "We
want to hold ourselves accountable." Does this practice demonstrate effective or ineffective
leadership? - correct answer ✔✔ Effective leadership: Being transparent, even about poor
results, is a mark of a good leader.
Good leaders know that leaders are highly visible — and they therefore set examples for others.
A leader who seeks transparency in her followers must demonstrate the same quality herself.
This appears to be an example of which of the following? - correct answer ✔✔ Unfair
attribution of blame
Although multiple providers were involved in these near-misses and mistakes, only one provider
was asked to leave. This is not fair, because others clearly could have made (and did make) the
same mistake, suggesting the problem was based in a system error rather than reckless
behavior by an individual.
Training Guide
According to WHO, in developed countries worldwide, what is the approximate likelihood that a
hospitalized patient will be harmed while receiving care? - correct answer ✔✔ 10%
According to WHO, in developed countries up to 10 percent of hospital patients may be harmed
while receiving care.
Since the publication of To Err Is Human in 1999, the health care industry overall has seen which
of the following improvements? - correct answer ✔✔ Wider awareness that preventable errors
are a problem
More than a decade after the publication of To Err Is Human, there is now wide recognition
throughout health care that the number of errors is way too high. Although this awareness has
not yet led to consistently lower rates of preventable medical error, progress is being made.
Health care organizations have begun to realize and accept that most errors cannot be linked to
the performance of individuals, but rather to the systems in which they function.
Safety has been called a "dynamic non-event" because when humans are in a potentially
hazardous environment: - correct answer ✔✔ It takes significant work to ensure nothing bad
happens
The best answer is it takes significant work to ensure nothing bad happens. When things go
right in a potentially hazardous environment, nothing bad happens. But in order for this "non-
event" of nothing going wrong to occur, a lot of things must be done right. Thus, safety has been
described as a "dynamic non-event."
To prevent this type of error from recurring in this unit, which of the following is MOST
important? - correct answer ✔✔ An improved culture of safety and teamwork
, Had there been a culture of safety fostering better teamwork, this error may well have been
prevented. In this case, when James asked Maria for help, she made him feel bad instead of
being a team player. In this type of environment, James may be reluctant to ask for help, even if
he is more closely supervised. We can generally assume that health care providers do not want
to harm their patients, so the threat of punishment is not the best way to prevent mistakes.
Although errors may occur when there is no recognized best practice, in the case of IV fluid
replacement, clear recommendations do exist.
Who is likely to be negatively affected by this medical error? - correct answer ✔✔ All of the
above
The best answer is all of the above. Patients and families are not the only ones affected when a
medical error occurs. In this case, James is likely to be devastated, and Maria may be affected as
well. Some providers even leave their profession after committing errors leading to a death.
One hospital CEO insists on including performance data in the hospital's annual report. "We do
very well on most measures, except for one or two, but we put those in anyway," she says. "We
want to hold ourselves accountable." Does this practice demonstrate effective or ineffective
leadership? - correct answer ✔✔ Effective leadership: Being transparent, even about poor
results, is a mark of a good leader.
Good leaders know that leaders are highly visible — and they therefore set examples for others.
A leader who seeks transparency in her followers must demonstrate the same quality herself.
This appears to be an example of which of the following? - correct answer ✔✔ Unfair
attribution of blame
Although multiple providers were involved in these near-misses and mistakes, only one provider
was asked to leave. This is not fair, because others clearly could have made (and did make) the
same mistake, suggesting the problem was based in a system error rather than reckless
behavior by an individual.
