CPPS IHI Practice Exam
In preparation for new antimicrobial stewardship regulatory requirements, a hospital is creating an
antimicrobial stewardship committee. What should be the first step in supporting this new patient
safety initiative?
A. Reach out to subject matter experts to gain insight on different compliance issues.
B. Work with information technology (IT) to build antibiotic indication and time-out screens.
C. Partner with key stakeholders to perform a gap analysis of current state to ideal state.
D. Review the past year's data to identify the most commonly grown pathogens. Correct Answer: C.
Partner with key stakeholders to perform a gap analysis of current state to ideal state.
After implementing a new product recall system, a hospital was alerted to a high-risk medication recall.
This medication is in stock in the emergency department and oncology unit. To ensure the effectiveness
of the new system, a patient safety professional should:
A. require individual departments to verify that a search for the recalled medication was performed.
B. ensure an on-site visit verifies that the recalled medication was sequestered.
C. reconcile the number of doses administered to the number of doses purchased.
D. notify the affected units via fax to remove recalled meds and to post recall notices in the units Correct
Answer: B. ensure an on-site visit verifies that the recalled medication was sequestered.
An organization is implementing a standardized surgical safety checklist and encounters resistance from
the perioperative staff. To improve staff engagement, a patient safety professional should:
A. prepare a business case for the implementation of the checklist.
B. present evidence that checklist use reduces practice variability.
C. assure staff that anesthesia is responsible for the checklist.
D. delegate checklist enforcement to nursing. Correct Answer: B. present evidence that checklist use
reduces practice variability.
An organization has achieved 92% compliance with a process measure. The patient safety professional
believes that the processes in place are not reliable or that the results are attributable to luck. Which of
the following best describes this characteristic?
A. appreciative inquiry
B. commitment to resilience
C. deference to expertise
D. preoccupation with failure Correct Answer: D. preoccupation with failure
A just culture framework provides a means to address behaviors that undermine a culture of safety
because
A. single outbursts are differentiated from consciously chosen acts.
B. preservation of highly valued team members is a primary goal.
C. the evaluative process does not consider personal performance-shaping factors.
D. the organizational response to investigated events is independent of patient outcome. Correct
Answer: D. the organizational response to investigated events is independent of patient outcome.
In process improvement, reducing variation improves
A. predictability of outcomes.
,B. patient care processes.
C. frequency of poor results.
D. reluctance to simplify. Correct Answer: A. predictability of outcomes.
When creating action plans, which of the following solutions would be considered the weakest?
A. visible involvement and action by leadership
B. standardizing processes as much as possible
C. creating access barriers to high-risk medications
D. use of color-coded labels that are readily seen by staff Correct Answer: D. use of color-coded labels
that are readily seen by staff
Which of the following is emphasized in crew resource management?
A. care standards
B. team leadership
C. caregiver burnout
D. health literacy Correct Answer: B. team leadership
10.
As a result of an adverse drug event, a patient required renal dialysis. A patient safety professional and
other leaders are discussing what to disclose to the patient. In addition to an apology, critical
components of disclosure include
A. a commitment to investigate what happened and how future errors will be prevented.
B. who was involved, when it happened, and how often medication errors occur.
C. plans for staff disciplinary action, physician disciplinary action, and a plan for education.
D. history of pharmacy transcription errors, and the plan to implement an electronic health record.
Correct Answer: A. a commitment to investigate what happened and how future errors will be
prevented.
Results from recent tests were not included in a patient transfer from one facility to another, resulting in
an adverse event. Which of the following is the most common cause of this type of harm?
A. inadequate information flow
B. inattentional blindness
C. normalized deviance
D. insufficient staffing Correct Answer: A. inadequate information flow
A healthcare organization is introducing a new medication administration barcoding system. Which of
the following is the most significant indicator of successful implementation?
A. order accuracy for high-risk medications
B. bar code scanning compliance
C. nursing bar coding knowledge
D. bar coding performance goal setting Correct Answer: B. bar code scanning compliance
A manager demonstrates adherence to the principles of a just culture by applying which of the following
types of decision-making frameworks?
A. harm-based
B. outcome-focused
C. equity-focused
D. risk-based Correct Answer: D. risk-based
,When interpreting data after a safety event, which of the following is true?
A. Identifying human error results in a deep understanding of the event and its causes.
B. Comparing actions taken to procedures and rules will explain the behaviors during the event.
C. The outcome of the event has no influence on the interpretation or conclusions.
D. Causes are constructed from the investigation and analysis. Correct Answer: D. Causes are
constructed from the investigation and analysis.
As a member of an improvement team focused on standardizing surgical protocols, the patient safety
professional recognizes that one concern clinicians may raise is:
A. improved supply chain management.
B. increased amount of waste.
C. depersonalized care.
D. increased length of stay. Correct Answer: C. depersonalized care.
When healthcare providers are involved in an adverse event, it is important to first
A. conduct an objective root cause analysis.
B. offer guidance and emotional support.
C. involve crisis counselors in the investigation.
D. consult providers who experienced a similar event. Correct Answer: B. offer guidance and emotional
support.
Which of the following is an example of a syndrome characterized by emotional exhaustion and a
decrease in personal accomplishments that is directly associated with employment?
A. burnout
B. grit
C. resilience
D. failure to thrive Correct Answer: A. burnout
When processing an order for diagnostic imaging of a patient's left foot, the nurse remembered
changing the dressing on the right foot. The nurse called the provider to confirm the laterality, and the
order was corrected. Which critical feature of the culture of safety did the nurse practice?
A. measurement of patient safety
B. ensuring all orders are carried out
C. awareness of health education
D. detection of a near miss Correct Answer: D. detection of a near miss
Which of the following is an example of a high reliability principle?
A. individual accountability
B. sensitivity to operations
C. executive patient safety rounds
D. adoption of cutting edge technology Correct Answer: B. sensitivity to operations
Despite pre-procedure screening for scheduled MRIs, patients with implanted devices presented for
scheduled MRI procedures. Technicians identified the hazards and prevented patients from entering the
suite. The most effective action for the patient safety professional is to recommend
A. using track and trend reports for repeat occurrences.
B. suspending provider MRI ordering privileges for repetitive noncompliance.
, C. requiring providers and staff to complete a safety training program.
D. collaborating with providers and staff to strengthen the screening process. Correct Answer: D.
collaborating with providers and staff to strengthen the screening process.
Which of the following statements about root cause analysis (RCA) is accurate?
A. The goal of performing an RCA is to find the one underlying root cause.
B. RCAs are not subject to outcome or hindsight biases.
C. RCAs may be subject to political highjack, resulting in poor risk controls.
D. RCAs are as effective in healthcare as they are in other high-risk industries. Correct Answer: C. RCAs
may be subject to political highjack, resulting in poor risk controls.
Which of the following is accurate when a patient has back-to-back procedures, and the person
performing each procedure changes?
A. No staff changes may occur between procedures.
B. One time-out at the beginning of the first surgery is sufficient for each procedure.
C. Another time-out needs to be performed before starting each procedure.
D. No additional sponge count is needed between surgeries. Correct Answer: C. Another time-out needs
to be performed before starting each procedure.
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 Correct 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. Correct 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 Correct 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. Correct 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
In preparation for new antimicrobial stewardship regulatory requirements, a hospital is creating an
antimicrobial stewardship committee. What should be the first step in supporting this new patient
safety initiative?
A. Reach out to subject matter experts to gain insight on different compliance issues.
B. Work with information technology (IT) to build antibiotic indication and time-out screens.
C. Partner with key stakeholders to perform a gap analysis of current state to ideal state.
D. Review the past year's data to identify the most commonly grown pathogens. Correct Answer: C.
Partner with key stakeholders to perform a gap analysis of current state to ideal state.
After implementing a new product recall system, a hospital was alerted to a high-risk medication recall.
This medication is in stock in the emergency department and oncology unit. To ensure the effectiveness
of the new system, a patient safety professional should:
A. require individual departments to verify that a search for the recalled medication was performed.
B. ensure an on-site visit verifies that the recalled medication was sequestered.
C. reconcile the number of doses administered to the number of doses purchased.
D. notify the affected units via fax to remove recalled meds and to post recall notices in the units Correct
Answer: B. ensure an on-site visit verifies that the recalled medication was sequestered.
An organization is implementing a standardized surgical safety checklist and encounters resistance from
the perioperative staff. To improve staff engagement, a patient safety professional should:
A. prepare a business case for the implementation of the checklist.
B. present evidence that checklist use reduces practice variability.
C. assure staff that anesthesia is responsible for the checklist.
D. delegate checklist enforcement to nursing. Correct Answer: B. present evidence that checklist use
reduces practice variability.
An organization has achieved 92% compliance with a process measure. The patient safety professional
believes that the processes in place are not reliable or that the results are attributable to luck. Which of
the following best describes this characteristic?
A. appreciative inquiry
B. commitment to resilience
C. deference to expertise
D. preoccupation with failure Correct Answer: D. preoccupation with failure
A just culture framework provides a means to address behaviors that undermine a culture of safety
because
A. single outbursts are differentiated from consciously chosen acts.
B. preservation of highly valued team members is a primary goal.
C. the evaluative process does not consider personal performance-shaping factors.
D. the organizational response to investigated events is independent of patient outcome. Correct
Answer: D. the organizational response to investigated events is independent of patient outcome.
In process improvement, reducing variation improves
A. predictability of outcomes.
,B. patient care processes.
C. frequency of poor results.
D. reluctance to simplify. Correct Answer: A. predictability of outcomes.
When creating action plans, which of the following solutions would be considered the weakest?
A. visible involvement and action by leadership
B. standardizing processes as much as possible
C. creating access barriers to high-risk medications
D. use of color-coded labels that are readily seen by staff Correct Answer: D. use of color-coded labels
that are readily seen by staff
Which of the following is emphasized in crew resource management?
A. care standards
B. team leadership
C. caregiver burnout
D. health literacy Correct Answer: B. team leadership
10.
As a result of an adverse drug event, a patient required renal dialysis. A patient safety professional and
other leaders are discussing what to disclose to the patient. In addition to an apology, critical
components of disclosure include
A. a commitment to investigate what happened and how future errors will be prevented.
B. who was involved, when it happened, and how often medication errors occur.
C. plans for staff disciplinary action, physician disciplinary action, and a plan for education.
D. history of pharmacy transcription errors, and the plan to implement an electronic health record.
Correct Answer: A. a commitment to investigate what happened and how future errors will be
prevented.
Results from recent tests were not included in a patient transfer from one facility to another, resulting in
an adverse event. Which of the following is the most common cause of this type of harm?
A. inadequate information flow
B. inattentional blindness
C. normalized deviance
D. insufficient staffing Correct Answer: A. inadequate information flow
A healthcare organization is introducing a new medication administration barcoding system. Which of
the following is the most significant indicator of successful implementation?
A. order accuracy for high-risk medications
B. bar code scanning compliance
C. nursing bar coding knowledge
D. bar coding performance goal setting Correct Answer: B. bar code scanning compliance
A manager demonstrates adherence to the principles of a just culture by applying which of the following
types of decision-making frameworks?
A. harm-based
B. outcome-focused
C. equity-focused
D. risk-based Correct Answer: D. risk-based
,When interpreting data after a safety event, which of the following is true?
A. Identifying human error results in a deep understanding of the event and its causes.
B. Comparing actions taken to procedures and rules will explain the behaviors during the event.
C. The outcome of the event has no influence on the interpretation or conclusions.
D. Causes are constructed from the investigation and analysis. Correct Answer: D. Causes are
constructed from the investigation and analysis.
As a member of an improvement team focused on standardizing surgical protocols, the patient safety
professional recognizes that one concern clinicians may raise is:
A. improved supply chain management.
B. increased amount of waste.
C. depersonalized care.
D. increased length of stay. Correct Answer: C. depersonalized care.
When healthcare providers are involved in an adverse event, it is important to first
A. conduct an objective root cause analysis.
B. offer guidance and emotional support.
C. involve crisis counselors in the investigation.
D. consult providers who experienced a similar event. Correct Answer: B. offer guidance and emotional
support.
Which of the following is an example of a syndrome characterized by emotional exhaustion and a
decrease in personal accomplishments that is directly associated with employment?
A. burnout
B. grit
C. resilience
D. failure to thrive Correct Answer: A. burnout
When processing an order for diagnostic imaging of a patient's left foot, the nurse remembered
changing the dressing on the right foot. The nurse called the provider to confirm the laterality, and the
order was corrected. Which critical feature of the culture of safety did the nurse practice?
A. measurement of patient safety
B. ensuring all orders are carried out
C. awareness of health education
D. detection of a near miss Correct Answer: D. detection of a near miss
Which of the following is an example of a high reliability principle?
A. individual accountability
B. sensitivity to operations
C. executive patient safety rounds
D. adoption of cutting edge technology Correct Answer: B. sensitivity to operations
Despite pre-procedure screening for scheduled MRIs, patients with implanted devices presented for
scheduled MRI procedures. Technicians identified the hazards and prevented patients from entering the
suite. The most effective action for the patient safety professional is to recommend
A. using track and trend reports for repeat occurrences.
B. suspending provider MRI ordering privileges for repetitive noncompliance.
, C. requiring providers and staff to complete a safety training program.
D. collaborating with providers and staff to strengthen the screening process. Correct Answer: D.
collaborating with providers and staff to strengthen the screening process.
Which of the following statements about root cause analysis (RCA) is accurate?
A. The goal of performing an RCA is to find the one underlying root cause.
B. RCAs are not subject to outcome or hindsight biases.
C. RCAs may be subject to political highjack, resulting in poor risk controls.
D. RCAs are as effective in healthcare as they are in other high-risk industries. Correct Answer: C. RCAs
may be subject to political highjack, resulting in poor risk controls.
Which of the following is accurate when a patient has back-to-back procedures, and the person
performing each procedure changes?
A. No staff changes may occur between procedures.
B. One time-out at the beginning of the first surgery is sufficient for each procedure.
C. Another time-out needs to be performed before starting each procedure.
D. No additional sponge count is needed between surgeries. Correct Answer: C. Another time-out needs
to be performed before starting each procedure.
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 Correct 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. Correct 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 Correct 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. Correct 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
