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CPPS IHI PRACTICE EXAM EXAM SCRIPT 2026
FULL SOLUTION PRACTICE
◉ Which of the following is most important in building a culture of safety? A. measuring safety outcomes B. addressing burnout C. establishing shared values D. utilizing electronic health records Answer: C. establishing shared values ◉ A practitioner reads a groundbreaking study on a condition seen frequently in their practice. Coincidentally, the next patient that the practitioner sees has symptoms commonly seen with that condition. Which of the following biases or heuristics best describes this phenomena? A. anchoring 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.
◉ When evaluating the conduct of a healthcare worker in the aftermath of a harm event, which of the following considerations demonstrate consistency with the principles of a fair and just culture? A. the severity of the injury that occurred B. alignment with state health department regulations C. the impact to the organization's reputation D. the practice of similarly qualified individuals Answer: D. the practice of similarly qualified individuals ◉ A patient safety professional receives an event report stating that a physician ordered anticoagulation medication to be discontinued through the physician order entry system. The pharmacy computer system did not receive the order, and the patient received four extra doses of the medication before the order was identified to be discontinued. The patient safety professional's investigation should focus on A. software interfaces. B. decision support. 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.
A. Re-survey the staff to obtain a higher response rate. B. Form a task force to address the questions on the safety survey. C. Interpret the results with caution due to the response rate. D. Contact the managers of the units to identify non-responders. Answer: C. Interpret the results with caution due to the response rate. ◉ On studying the results of a root cause analysis, it is recognized that an RN missed steps in a protocol. The RN is regarded as highly competent by colleagues and unit leaders. The patient safety professional should determine the RN's behavior in this error to be considered A. workaround. B. reckless. C. high risk. D. drift. Answer: D. drift. ◉ Patient safety is considered a subset of quality, but it is more difficult to measure in part because 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.
experienced severe abdominal pain, showed signs of sepsis, and was found to have an abdominal perforation. Which cognitive process best describes the on-call physician's response? A. hindsight bias B. implicit bias C. normalization of the deviant D. recall bias Answer: B. implicit bias ◉ A hospital is using the AHRQ Hospital Survey on Patient Safety Culture. There were 80 employees who responded. Responses to the survey item that states "we have patient safety problems in this unit" were as follows: · Strongly Agree: 16 · Agree: 32 · Neither Agree nor Disagree: 12 · Disagree: 17 · Strongly Disagree: 3 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
peer review, to look for common causes and assess the best course of action, including whether to proceed with RCA. ◉ At the conclusion of a surgical procedure at your hospital, the instrument count is incorrect. The hospital policy does not stipulate that the surgeon must remain on the premises until an x-ray is obtained to check for retained foreign objects. By the time the x-ray results come in to reveal that there is, in fact, a retained instrument, the original surgeon has left the hospital to catch a flight. Another surgeon is contacted to remove the retained instrument. How should leadership respond to this event? A. Re-educate the OR nursing staff on keeping track of instruments on the sterile field. B. Revise the hospital policy to make it clear that surgeons must stay in the operating room (OR) until instrument count issues are resolved. C. Using an appropriate accountability system, counsel the surgeon about customary clinical standards. 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
C. Review annual data on defects and successes. D. Focus on a list of projects identified by senior stakeholders. Answer: B. Apply best evidence with the goal of failure-free operation over time. In the IHI Framework for Safe, Reliable, and Effective Care, the role of patient safety specialists is to apply best evidence with the goal of failure-free operation over time. This involves reviewing data frequently (much more often than annually), designing systems to help people make the right choice (rather than relying on education to change behavior), and setting priorities in collaboration with senior stakeholders (rather than solely at their direction). ◉ 1. At the end of a long, exhausting shift, an experienced nurse administered the wrong medication by picking up the wrong syringe. The wrong medication was an analgesic, and the patient didn't suffer any problems. After recalling that his colleague was fired last month over a medication error, he decides not to file an 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
A. Finding the individual to blame B. Managing behavioral choices C. Providing punishment equal to the harm caused D. Decreasing the amount of reported errors Answer: B. Managing behavioral choices A Just Culture is a learning culture in which people learn from mistakes and/or potential mistakes. In a Just Culture, people look at all the factors that led to a harm event (or factors that may lead to harm), including behavioral choices, so that future harm can be prevented. Finding the individual to blame is incorrect because in a Just Culture, the focus is on system failures. Providing punishment equal to the severity of harm is incorrect because in a Just Culture, punishment is related to intent to do harm. Decreasing the amount of reported errors is incorrect because in a Just Culture, you would actually expect an increase of reported errors, especially related to near misses and/or great catches. ◉ A nurse on a medical-surgical unit does not comply with the barcode medication administration (BCMA) procedure while caring for one of her patients. Her supervisor is deciding how to respond. As her supervisor, what would you do? A. Request that the pharmacy run a report of the BCMA compliance rates of the unit. B. Ask staff if there are adequate scanners to meet their needs.
C. Ask the nurse what was occurring at the time, and why she chose to bypass the policy. D. Counsel the nurse on the importance of following policy. Answer: C. Ask the nurse what was occurring at the time and why she chose to bypass the policy. In determining the appropriate response to a violation of policy, it is important to learn what the incentive was for the behavior and what conditions led the staff member to their action. The Just Culture algorithm can serve as a guide. In this case, it is important to understand the nurse's rationale for diverting from the policy. For example, did she think the benefit outweighed the risk for some reason? ◉ Which of the following is the best first step in changing the culture of safety in a health care organization? A. Develop policies, procedures, and checklists for safety. B. Hire an experienced patient safety officer with a strong performance record. C. Conduct an assessment and gather focused data. D. Implement communication and teamwork tools. Answer: C. Conduct an assessment and gather focused data. As a first step in improving the culture, an assessment and data review are necessary to determine the current strengths and
