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CPPS EXAM PREP 2026 | 300+ VERIFIED Q&A |
PATIENT SAFETY MASTERY |
MAPPED TO IHI DOMAINS (WITH RATIONALES)
You are a patient safety officer for a community hospital that has had many falls resulting
in serious injuries. A "No Pass Zone" initiative was piloted on one of the units several
months ago. You are scheduled to present the results of the pilot to leadership. Your goal is
to get leadership's buy in to implement the "No Pass Zone" initiative throughout the entire
hospital.
What chart would be best to show leadership the impact of the "No Pass Zone" initiative
over time?
A.) Run chart
B.) Pareto chart
C.) Shewhart chart
D.) Control chart
A.) Run chart
A run chart studies variation in data over time and is the best option to help the hospital leaders
understand the impact of changes on measures.In regard to the other answer options: A Pareto
chart focuses on areas of improvement with greatest impact. Shewhart charts, also known as
control charts, distinguish between special cause and common causes of variation. A control
chart could be used in this instance, but a run chart is simpler and would be sufficient to answer
the key question about improvement over time.
A patient safety professional is monitoring incident reports submitted for near misses and
minor events to identify areas of potential patient safety risk. Over the last few months,
there has been a steady decline in the number of reports being submitted each week. There
have been some leadership changes, but the staff has been stable with no major personnel
,2|Page
issues.
Which of the following actions should be taken in response to this change?
A.) Issue a message to the staff that failure to report can lead to discipline.
B.) Ensure reporting is being emphasized and feedback on submitted reports is occurring.
C.) Report the data as a positive trend and celebrate the improved performance.
D.) Continue to monitor for fluctuations; no action is required at this time.
B.) Ensure reporting is being emphasized and feedback on submitted reports is occurring.
James Reason said a reporting culture is required to create a strong safety culture. Leaders should
positively reinforce reporting without threats of discipline. To maintain reporting, reporters need
feedback that indicates the reports are being used. A decline in reporting is not a positive
situation because it suggests problems remain unreported and unresolved.
A patient safety officer has been asked to compare the incidence of medication omissions on
two medical surgical units. To normalize the data, the patient safety officer should compare
the:
A.) Medication omissions per administered dose on each unit
B.) Total number of medication errors on each unit
C.) Total number of medication omissions on each unit
D.) Medication errors per administered dose on each unit
A.) Medication omissions per administered dose on each unit
The patient safety officer has been asked to look at medication omissions, not all medication
errors, so medication omissions per administered dose on each unit would be the correct answer.
To normalize the data for accurate comparison, the patient safety officer needs to compare rates
(as opposed to total numbers).
A root cause analysis team has recommended the following action item: "The manager will
provide the care team with training on the proper use of personal protective equipment
required while caring for a patient with tuberculosis."
Which of the following is a process measure the team might use?
A.) The number of personal protective equipment purchased
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B.) The percentage of staff observed to be correctly using personal protective equipment
C.) Percentage of staff with positive TB skin tests
D.) The number of reported staff exposures to tuberculosis
B.) The percentage of staff observed to be correctly using personal protective equipment
The percentage of staff observed to be correctly using personal protective equipment is the best
example of a process measure. The other answer options are examples of outcome measures.
An example of a descriptive statistics measure for central tendency is:
A.) Mode
B.) Range
C.) Standard error of the mean
D.) Standard deviation
A.) Mode
Mode is a measure of central tendency. Range, standard deviation, and standard error of the
mean are measures of variation.
Which of the following is considered to be a scientific method of process improvement for
testing a change in a real work setting?
A.) Event analysis
B.) Root cause analysis (RCA)
C.) Failure mode and effects analysis (FMEA)
D.) Plan-Do-Study-Act (PDSA) cycle
D.) Plan-Do-Study-Act (PDSA) cycle
The PDSA cycle is a scientific method of process improvement that involves planning the
change, trying it, observing it, and acting on what is learned. It serves as a guide for testing a
change in a real work setting. RCA and event analysis are used mostly in identifying causes
related to an adverse event. FMEA is utilized in identifying potential failures before a new
process is implemented.
, 4|Page
Systems thinking encourages organizations to approach cause analysis through:
A.) Recognizing people are fallible and experience errors in which system factors are the
major cause
B.) Understanding individuals alone need to act reliably and avoid error to make patient
care safer
C.) Acknowledging the system alone is responsible for safety, and all individual failures
indicate a deficiency in the system
D.) Identifying and removing poor performers to maintain system performance
A.) Recognizing people are fallible and experience errors in which system factors are the major
cause
Health care has made strides in realizing errors occur because there are imperfect people working
in imperfect systems.
Removing "poor performers" without addressing systems issue will not prevent adverse events
from recurring; in most cases, there were failures further upstream from the event that allowed it
to occur.In regard to the other answer options: Acknowledging the system alone is responsible is
inaccurate because, at times, there are individual failures when the system in place did not fail.
Telling individuals to "act reliably" will not prevent human error or make systems safer.
Referring to the story of the nurse named Karen: Which of the following are human factors
issue that contributed to the event? Choose all that apply.
Hand-off problems
Fatigue
Distractions
Reliance on memory
Look-alike equipment
All of the possible answers are correct.
There were hand-off problems and distractions and there was fatigue and reliance on
memory.There was also the issue of human nature when Karen first tried to connect the cables; it
CPPS EXAM PREP 2026 | 300+ VERIFIED Q&A |
PATIENT SAFETY MASTERY |
MAPPED TO IHI DOMAINS (WITH RATIONALES)
You are a patient safety officer for a community hospital that has had many falls resulting
in serious injuries. A "No Pass Zone" initiative was piloted on one of the units several
months ago. You are scheduled to present the results of the pilot to leadership. Your goal is
to get leadership's buy in to implement the "No Pass Zone" initiative throughout the entire
hospital.
What chart would be best to show leadership the impact of the "No Pass Zone" initiative
over time?
A.) Run chart
B.) Pareto chart
C.) Shewhart chart
D.) Control chart
A.) Run chart
A run chart studies variation in data over time and is the best option to help the hospital leaders
understand the impact of changes on measures.In regard to the other answer options: A Pareto
chart focuses on areas of improvement with greatest impact. Shewhart charts, also known as
control charts, distinguish between special cause and common causes of variation. A control
chart could be used in this instance, but a run chart is simpler and would be sufficient to answer
the key question about improvement over time.
A patient safety professional is monitoring incident reports submitted for near misses and
minor events to identify areas of potential patient safety risk. Over the last few months,
there has been a steady decline in the number of reports being submitted each week. There
have been some leadership changes, but the staff has been stable with no major personnel
,2|Page
issues.
Which of the following actions should be taken in response to this change?
A.) Issue a message to the staff that failure to report can lead to discipline.
B.) Ensure reporting is being emphasized and feedback on submitted reports is occurring.
C.) Report the data as a positive trend and celebrate the improved performance.
D.) Continue to monitor for fluctuations; no action is required at this time.
B.) Ensure reporting is being emphasized and feedback on submitted reports is occurring.
James Reason said a reporting culture is required to create a strong safety culture. Leaders should
positively reinforce reporting without threats of discipline. To maintain reporting, reporters need
feedback that indicates the reports are being used. A decline in reporting is not a positive
situation because it suggests problems remain unreported and unresolved.
A patient safety officer has been asked to compare the incidence of medication omissions on
two medical surgical units. To normalize the data, the patient safety officer should compare
the:
A.) Medication omissions per administered dose on each unit
B.) Total number of medication errors on each unit
C.) Total number of medication omissions on each unit
D.) Medication errors per administered dose on each unit
A.) Medication omissions per administered dose on each unit
The patient safety officer has been asked to look at medication omissions, not all medication
errors, so medication omissions per administered dose on each unit would be the correct answer.
To normalize the data for accurate comparison, the patient safety officer needs to compare rates
(as opposed to total numbers).
A root cause analysis team has recommended the following action item: "The manager will
provide the care team with training on the proper use of personal protective equipment
required while caring for a patient with tuberculosis."
Which of the following is a process measure the team might use?
A.) The number of personal protective equipment purchased
,3|Page
B.) The percentage of staff observed to be correctly using personal protective equipment
C.) Percentage of staff with positive TB skin tests
D.) The number of reported staff exposures to tuberculosis
B.) The percentage of staff observed to be correctly using personal protective equipment
The percentage of staff observed to be correctly using personal protective equipment is the best
example of a process measure. The other answer options are examples of outcome measures.
An example of a descriptive statistics measure for central tendency is:
A.) Mode
B.) Range
C.) Standard error of the mean
D.) Standard deviation
A.) Mode
Mode is a measure of central tendency. Range, standard deviation, and standard error of the
mean are measures of variation.
Which of the following is considered to be a scientific method of process improvement for
testing a change in a real work setting?
A.) Event analysis
B.) Root cause analysis (RCA)
C.) Failure mode and effects analysis (FMEA)
D.) Plan-Do-Study-Act (PDSA) cycle
D.) Plan-Do-Study-Act (PDSA) cycle
The PDSA cycle is a scientific method of process improvement that involves planning the
change, trying it, observing it, and acting on what is learned. It serves as a guide for testing a
change in a real work setting. RCA and event analysis are used mostly in identifying causes
related to an adverse event. FMEA is utilized in identifying potential failures before a new
process is implemented.
, 4|Page
Systems thinking encourages organizations to approach cause analysis through:
A.) Recognizing people are fallible and experience errors in which system factors are the
major cause
B.) Understanding individuals alone need to act reliably and avoid error to make patient
care safer
C.) Acknowledging the system alone is responsible for safety, and all individual failures
indicate a deficiency in the system
D.) Identifying and removing poor performers to maintain system performance
A.) Recognizing people are fallible and experience errors in which system factors are the major
cause
Health care has made strides in realizing errors occur because there are imperfect people working
in imperfect systems.
Removing "poor performers" without addressing systems issue will not prevent adverse events
from recurring; in most cases, there were failures further upstream from the event that allowed it
to occur.In regard to the other answer options: Acknowledging the system alone is responsible is
inaccurate because, at times, there are individual failures when the system in place did not fail.
Telling individuals to "act reliably" will not prevent human error or make systems safer.
Referring to the story of the nurse named Karen: Which of the following are human factors
issue that contributed to the event? Choose all that apply.
Hand-off problems
Fatigue
Distractions
Reliance on memory
Look-alike equipment
All of the possible answers are correct.
There were hand-off problems and distractions and there was fatigue and reliance on
memory.There was also the issue of human nature when Karen first tried to connect the cables; it
