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CPPS IHI PRACTICE EXAM 2026 EXAM SCRIPT
COMPLETE SOLUTIONS
◉ Which of the following is most useful in illustrating inefficiency and waste in a process? A. fishbone diagram B. control chart C. spaghetti chart D. Pareto diagram Answer: C. spaghetti chart ◉ Measurement of hospital-acquired pressure injuries would be an example of A. an outcome measure. B. a process measure. C. a balance measure. D. an evidence-based measure. Answer: A. an outcome measure. ◉ What type of organization recognizes and respects that information can come from any source within the organization and that each reporter has a valuable perspective? A. highly reliable B. diverse
C. patient-centered D. interdisciplinary Answer: A. highly reliable ◉ From a human factors engineering perspective, which of the following should beknown about identifying and eliminating diagnostic errors? A. Diagnostic errors are the result of cognitive biases and failures by clinicians. B. Partnership with scientists in cognition, perception, and decision making is needed. C. An effective strategy to reduce diagnostic errors is the use of checklists. D. Attribution of diagnostic errors is not subject to either hindsight or outcome biases. Answer: B. Partnership with scientists in cognition, perception, and decision making is needed. ◉ Which of the following would best demonstrate non-random process variation over time? A. histogram B. control chart C. run chart D. pie chart Answer: B. control chart
B. availability C. premature closure D. risk aversion Answer: B. availability ◉ While investigating a near miss medication event, a manager identifies a pattern of work arounds by a clinician that violates policies and procedures. To determine accountability, the manager's next step should be to A. conduct a focus group with work area staff. B. perform a substitution test. C. escalate the workarounds to leadership. D. amend procedures to support the workarounds. Answer: B. perform a substitution test. ◉ A physician is planning to discharge a patient. The nurse knew that the patient needed additional equipment at home. Together they reached out to the social worker and discharge planner for a safe care transition. Which feature of the culture of safety did they practice? A. activation of transfer protocols B. utilization of open communication C. measurement of patient safety D. ensuring health literacy Answer: B. utilization of open communication
◉ From a human factors standpoint, which of the following is true about harmduring healthcare? A. It is either due to system errors or intentional human choice. B. It would not occur if healthcare workers followed rules. C. It is prevented by healthcare workers adapting to changes. D. It is always preventable; the goal is zero harm. Answer: C. It is prevented by healthcare workers adapting to changes. ◉ A patient safety professional notes an increase in safety events involving insulin. Which of the following strategies is most likely to result in improvement? A. The quality committee requires monthly progress reports on departmental insulin safety plans. B. The pharmacy and therapeutics committee introduces two insulin products to the formulary. C. The pharmacy educates on insulin safety by distributing a tip sheet to nursing and providers. D. The medication safety committee monitors reports on insulin administration errors. Answer: A. The quality committee requires monthly progress reports on departmental insulin safety plans. ◉ Of the following steps, which should be done first when conducting an FMEA?
C. patient identification. D. business intelligence. Answer: A. software interfaces. ◉ Which of the following concepts describes a situation where violations of safe practices become regarded as acceptable and are generally tolerated by the group? A. standards of practice B. inattentional blindness C. normalized deviance D. situational bias Answer: C. normalized deviance ◉ Which of the following types of errors is due to a previous management decision that impacted design, resulting in patient harm? A. active error B. commission error C. latent error D. omission error Answer: C. latent error ◉ An incident report relates that a nurse who completed a 12-hour shift on a newly opened ward forgot to document a skin assessment in the patient's medical record. This is an example of A. human error.
B. careless action. C. at-risk behavior. D. recklessness. Answer: A. human error. ◉ Which of the following actions provides evidence that a healthcare organization considers patients' experiences to improve the safety of patientcare? A. Consumers, payors, and administrators are represented on committees. B. Patients receive experience surveys after reviewing charges. C. Patient feedback is used to redesign care processes. D. Patient involvement is publicly recognized. Answer: C. Patient feedback is used to redesign care processes. ◉ A new long-term care facility is being planned. Recognizing that resident injuries related to falls are a significant concern, a team has been convened to plan, implement, and evaluate potential solutions. Which of the following interventions will have the largest impact on the rate of injuries related to falls? A. Position grab bars in bathrooms. B. Attach egress alarms to residents. C. Locate floor pads next to beds. D. Install impact-absorbing flooring. Answer: D. Install impact- absorbing flooring.
A. identification of incidents often depends on self-reporting. B. caregivers are not held accountable to report incidents. C. incident reporting systems are always anonymous. D. of dependence on trigger tools to identify safety events. Answer: A. identification of incidents often depends on self-reporting. ◉ Leadership addressed an unrecognized latent threat in an existing workflow that was brought to their attention by frontline workers. This is an example of: A. preoccupation with failure. B. decentralized decision making. C. sensitivity to operations. D. commitment to resilience. Answer: C. sensitivity to operations. ◉ Leadership has been promoting fair and just culture concepts including non-punitive response to reporting and the value of near miss reporting. The plan is not universally supported, and some argue it is a waste of the facility's resources. To support this leadership initiative, a patient safety professional should explain that the plan is intended to result in A. a decrease in event reporting volume due to fewer actual adverse events. B. a decrease in event reporting due to fewer near misses.
C. an increase in event reporting that will decrease malpractice insurance premiums. D. an increase in event reporting that will help the hospital identify areas of risk. Answer: D. an increase in event reporting that will help the hospital identify areas of risk. ◉ Which of the following is the most appropriate method to determine if a root cause analysis (RCA) should be conducted on an adverse event? A. Consider only the outcome severity. B. Consider only blameworthy events. C. Utilize a risk-based prioritization system. D. Assess only the probability of recurrence. Answer: C. Utilize a risk- based prioritization system. ◉ Which of the following strategies is best for facilitating the acceptance of changer elated to specific performance improvement initiatives? A. Provide a quarterly statistical report. B. Utilize storytelling tools. C. Recognize leadership participation. D. Distribute weekly newsletters via e-mail. Answer: B. Utilize storytelling tools.
What is the Percent Positive Score that should be reported for this item? Answer: Correct Answer: 25% The AHRQ Hospital Survey on Patient Safety Culture User Guide scoring guidance says to use the "Strongly Agree/Agree" response sum, or, for negatively worded items—such as this one—use the "Strongly Disagree/Disagree" sum. In this example, 17+3 gives us the response sum (i.e., 20), which we divide by total number of respondents (i.e., 80): 20/80 = 25%. ◉ A staff member discovered a medication with an incorrect label. The staff immediately notified the pharmacist and the correct label was sent prior to medication administration. Then, the staff completed an event report through the organization's reporting tool. Which of the following actions should the unit manager take in response to this event? A. Document the incident in the employee's performance review. B. Investigate system failures and recognize the employee for reporting a near-miss event. C. Notify the director of pharmacy about the pharmacist's error. D. No action, since the incident did not cause patient harm. Answer: B. Investigate system failures and recognize the employee for reporting a near-miss event. In a culture of safety, staff members are free to report patient safety events, including close calls or near misses. Managers should have a non-punitive response to staff involved in errors and reward staff
who report safety issues. Even though the error did not reach the patient or cause harm, it needs further investigation to identify any system failures, and to ensure that a process is in place to prevent an error from reaching the patient and causing harm. ◉ You are educating clinical managers in your health care facility on how to identify appropriate events for conducting a root cause analysis (RCA). Which event provides the BEST opportunity for an RCA? A. A post-operative patient removes his own IV, causing a skin tear from the tape. B. A patient with no known allergies experiences an anaphylactic reaction to an antibiotic, requiring transfer to ICU. C. The biopsy samples from a colonoscopy are never received by pathology after the procedure. D. In the last four months, there have been three occurrences of depressed respirations related to sedation in the same department. Answer: C. The biopsy samples from a colonoscopy are never received by pathology after the procedure. Although a one-time event, the missing biopsy samples are the strongest contender for RCA because the problem may result in very significant harm (e.g., if there is no option for additional biopsy and a diagnosis cannot be made) and because the situation clearly represents deviation from practice standards, in this case related to chain of custody of a specimen. An RCA would identify the potential
D. Create a process map of how instruments are managed during surgery, looking for la Answer: C. Using an appropriate accountability system, counsel the surgeon about customary clinical standards. The surgeon made a choice to leave for personal reasons before receiving confirmation that his patient was safe. In the substitution test, other surgeons would likely consider it their responsibility to stay and assure the patient was object-free.Although the policy could clearly outline that a surgeon must stay until counts are confirmed, it is unrealistic for leaders to regulate every step of every process and practice: As health care professionals, surgeons already have a pre-existing, overarching duty to avoid causing unjustifiable risk or harm. In this case, counseling the surgeon likely does not mean pulling his privileges; it means having a conversation with him about the inappropriateness of the action he took and the potential impact on his patient. Sometimes individuals do share the responsibility for a deviation, and we need to hold professionals accountable for their portion of a situation even when system factors may also need improvement. ◉ The human resources department at your organization has asked your patient safety specialist for recommendations on new policies to help support safety culture. Which recommendation sounds best? A. Sending human resources all event data so that they can record involvement in adverse events in personnel files
B. Including human resources in all root cause analyses so that they can provide guidance on recommended training updates for staff C. Implementing routine use of a tool to determine which events are attributed to human error, at-risk behavior, and reckless behavior D. Implementing routine use of a tool to determine which events are attributed to human error, at-risk behavior, and reckless behavior AND consulting with human resources on at-risk and reckless behavior cases Answer: C. Implementing routine use of a tool to determine which events are attributed to human error, at-risk behavior, and reckless behavior AND consulting with human resources on at-risk and reckless behavior cases The first answer (sending human resources all event data so that they can record involvement in adverse events in personnel files) is incorrect because including all events in personnel files regardless of blame worthiness does not support a just culture. The second answer (including human resources in all root cause analyses so that they can provide guidance on recommended training updates for staff) is interesting but incorrect because recommendations for staff training could come out of the RCA process without the involvement of HR. The third answer (implementing routine use of a tool to determine which events are attributed to human error, at-risk behavior, and reckless behavior) is not correct because, while it makes the good suggestion of using a tool to distinguish among human error, at-risk behavior, and reckless behavior, it does not address what to do with that information; human resources should be consulted to help
incident report. Safety culture would be improved if the hospital provided this employee with which of the following? A. An electronic reporting system B. Psychological safety C. Situational awareness training D. Training on reporting Answer: B. Psychological safety In this case, regardless of whether the nurse has the knowledge or ability to report the error, he is not speaking up because he does not feel psychologically safe to do so. If the nurse felt psychologically safe, he would feel confident that his concern would be heard and that appropriate, system-focused action (as opposed to misplaced blame and punishment) would ensue. ◉ A staff nurse at your hospital fails to complete a double-check before administering a high-alert medication. She gives the medication to the incorrect patient, and the patient suffers an arrhythmia. When applying James Reason's unsafe acts algorithm, what is a strategy to use prior to holding the nurse personally accountable? A. Hold a root cause analysis. B. Perform the substitution test with three other nurses. C. Ask other nurses if the staff nurse is trustworthy. D. Have the chief nursing officer interview the nurse. Answer: B. Perform the substitution test with three other nurses.
Performing the substitution test, which entails asking other professionals if they would be likely to repeat the same behavior if placed in the same situation, is an effective way to assess whether a blameworthy event has occurred. In this case, if other individuals say they might have also skipped the double-check, it is fair to assume there is an underlying systems issue at fault for the nurse's actions, and she should not be held personally accountable. The other options listed are not reasonable methods to discern whether the problem is a systems issue or a blameworthy personnel issue. ◉ 1. To improve culture of safety survey results, which of the following should an organization do? A. Offer coaching and apply Just Culture principles to leaders in lower performing areas. B. Examine high-performing units to identify and disseminate best practices. C. Perform root cause analysis on underperforming units to better understand their results. D. Acknowledge and celebrate high-performing areas in front of leadership. Answer: B. Examine high-performing units to identify and disseminate best practices. Identifying bright spots and applying the learning to other settings is the best way to spread best practices. In regard to the other answer options: Applying Just Culture principles could be perceived as a
