CPPS IHI PRACTICE EXAM
A team is reviewing a serious harm event through the root cause analysis
process. Before it draws any conclusions about the accountability of the
provider(s) involved, what elements should the team consider?
A. How many years the individual has been practicing
B. Whether the individual filed a claim with risk management
C. The individual's most recent performance review
D. The contribution of systems factors on the individual's behavior -
ANSWERS-D. The contribution of systems factors on the individual's behavior.
The contribution of systems factors on the individual's behavior reflects just
culture principles and the proper approach to use before drawing conclusions
about accountability.
A hospital's patient safety team is exploring strategies to reduce the number of
patient identification errors in the lab specimen collection process. Which of the
following strategies will provide the highest impact in reduction of errors?
A. Revise the process to allow only one specimen label on the
nurse/phlebotomist tray at a time.
B. Educate all nurses and phlebotomists to ask about patient identifiers before
obtaining specimen.
C. Utilize barcode scanners to generate a specimen label at the bedside.
D. Standardize the process to require the nurse/phlebotomist to ask the patient
to state their name prior to the specimen collection. - ANSWERS-C. Utilize
barcode scanners to generate a specimen label at the bedside.
,Utilizing bar code scanners is the correct answer because it entails a forcing
function at the bedside. After scanning the armband, the correct label for that
patient will print from the scanner.
In regard to the other options: Education is always the lowest impact (soft fix)
in any action plan. Changing processes is better but will still rely on individuals
to do the right thing, e.g., the nurse/phlebotomist would need to make sure
multiple labels were not on the tray, which is a common shortcut to avoid
having to walk back and forth between specimen collections. Direct observation
would be required to make sure people didn't introduce workarounds.
In the context of failure modes and effects analysis (FMEA), how is the risk
priority number (RPN) used?
A. It prioritizes the failure modes that do not require action.
B. It specifies the failure modes that have been shown to cause harm.
C. It identifies the highest priority failure modes to address.
D. It calculates the failure modes that will create the most errors - ANSWERS-
C. It identifies the highest priority failure modes to address.
The Risk Priority Number (RPN) is a score that provides the team a way to
identify the highest risk failure modes in descending order. If the team does not
have the resources to address all the identified risks, this number can be used to
filter out failure modes that are acceptable in the current state.In regard to the
other answer options: The RPN does not determine that an action is not
required; that determination comes from the team evaluating the issue at hand,
and, to some degree, may be decided based on time and resources available. The
RPN does not identify error potential or represent harm that has already
occurred; it identifies the impact of a failure mode if it does occur.
Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS) is a process improvement program that can be used to:
,A. Reduce waste.
B. Find the root cause of an incident.
C. Help address disruptive behavior.
D. Eliminate variation. - ANSWERS-C. Help address disruptive behavior.
TeamSTEPPS can be used to increase communication skills with teams and
reduce the risk of miscommunication that can lead to disruptive behavior.
In regard to the other answer options: Finding the root cause of an incident is
performing a root cause analysis. Reducing waste is Lean process improvement,
and eliminating variation is Six Sigma.
Your organization utilizes a "home grown" electronic safety event reporting
system that is no longer meeting the needs of the organization. Hospital
administration is asking for your opinion: What would you do for next steps to
identify a replacement system?
A. Ask Information Systems to either fix the old system or build a new one.
B. Purchase the least expensive software.
C. Identify key stakeholders and perform a gap analysis of current state to ideal
state.
D. Poll colleagues and purchase what they use. - ANSWERS-C. Identify key
stakeholders and perform a gap analysis of current state to ideal state.
Performing a thorough search of available products that meet the standards for
the organization is the primary action you should take. Once the collated
information is obtained, convening a meeting with the key stakeholders
(nursing, medicine, finance, patient safety, legal, etc.) to determine the
organizational needs in relation to the intended financial impact and return on
investment may be required.
, Your hospital is considering implementing a robotic surgery program. As a
patient safety professional, you are concerned about the potential for patient
injury associated with this new technology. The most appropriate tool or
technique for assessing potential risks associated with implementation of the
new technology is:
A. Root cause analysis (RCA)
B. Patient safety leadership WalkRounds
C. Failure modes and effects analysis (FMEA)
D. Meaningful use evaluation - ANSWERS-C. Failure Modes and Effects
Analysis (FMEA)The best answer is FMEA.
FMEA is a prospective risk reduction strategy; ideally, it is used before a new
technology is implemented to determine how the new technology might fail and
cause harm. Patient safety leadership WalkRounds are designed to help leaders
gather facts about the care environment and create positive relationships
between staff and administration. Root cause analysis is a retrospective tool; it
is used after a harmful event or near miss to determine what went wrong.
Meaningful use evaluation is for evaluating the success of implementing an
electronic health record.
Your organization is preparing to change to a new electronic health record.
Many departments have been involved with the planning for this huge effort.
What would you suggest as part of the preparation strategy?
A. Offer to do a claims analysis for any related errors.
B. Suggest a Plan-Do-Study-Act (PDSA) cycle.
C. Conduct a failure modes and effects analysis (FMEA).
D. Conduct a root cause analysis (RCA). - ANSWERS-C. Conduct a failure
modes and effects analysis (FMEA).
FMEA would be valuable step for anticipating gaps in the planning so that
people can address potential problems before implementing the new system. A
A team is reviewing a serious harm event through the root cause analysis
process. Before it draws any conclusions about the accountability of the
provider(s) involved, what elements should the team consider?
A. How many years the individual has been practicing
B. Whether the individual filed a claim with risk management
C. The individual's most recent performance review
D. The contribution of systems factors on the individual's behavior -
ANSWERS-D. The contribution of systems factors on the individual's behavior.
The contribution of systems factors on the individual's behavior reflects just
culture principles and the proper approach to use before drawing conclusions
about accountability.
A hospital's patient safety team is exploring strategies to reduce the number of
patient identification errors in the lab specimen collection process. Which of the
following strategies will provide the highest impact in reduction of errors?
A. Revise the process to allow only one specimen label on the
nurse/phlebotomist tray at a time.
B. Educate all nurses and phlebotomists to ask about patient identifiers before
obtaining specimen.
C. Utilize barcode scanners to generate a specimen label at the bedside.
D. Standardize the process to require the nurse/phlebotomist to ask the patient
to state their name prior to the specimen collection. - ANSWERS-C. Utilize
barcode scanners to generate a specimen label at the bedside.
,Utilizing bar code scanners is the correct answer because it entails a forcing
function at the bedside. After scanning the armband, the correct label for that
patient will print from the scanner.
In regard to the other options: Education is always the lowest impact (soft fix)
in any action plan. Changing processes is better but will still rely on individuals
to do the right thing, e.g., the nurse/phlebotomist would need to make sure
multiple labels were not on the tray, which is a common shortcut to avoid
having to walk back and forth between specimen collections. Direct observation
would be required to make sure people didn't introduce workarounds.
In the context of failure modes and effects analysis (FMEA), how is the risk
priority number (RPN) used?
A. It prioritizes the failure modes that do not require action.
B. It specifies the failure modes that have been shown to cause harm.
C. It identifies the highest priority failure modes to address.
D. It calculates the failure modes that will create the most errors - ANSWERS-
C. It identifies the highest priority failure modes to address.
The Risk Priority Number (RPN) is a score that provides the team a way to
identify the highest risk failure modes in descending order. If the team does not
have the resources to address all the identified risks, this number can be used to
filter out failure modes that are acceptable in the current state.In regard to the
other answer options: The RPN does not determine that an action is not
required; that determination comes from the team evaluating the issue at hand,
and, to some degree, may be decided based on time and resources available. The
RPN does not identify error potential or represent harm that has already
occurred; it identifies the impact of a failure mode if it does occur.
Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS) is a process improvement program that can be used to:
,A. Reduce waste.
B. Find the root cause of an incident.
C. Help address disruptive behavior.
D. Eliminate variation. - ANSWERS-C. Help address disruptive behavior.
TeamSTEPPS can be used to increase communication skills with teams and
reduce the risk of miscommunication that can lead to disruptive behavior.
In regard to the other answer options: Finding the root cause of an incident is
performing a root cause analysis. Reducing waste is Lean process improvement,
and eliminating variation is Six Sigma.
Your organization utilizes a "home grown" electronic safety event reporting
system that is no longer meeting the needs of the organization. Hospital
administration is asking for your opinion: What would you do for next steps to
identify a replacement system?
A. Ask Information Systems to either fix the old system or build a new one.
B. Purchase the least expensive software.
C. Identify key stakeholders and perform a gap analysis of current state to ideal
state.
D. Poll colleagues and purchase what they use. - ANSWERS-C. Identify key
stakeholders and perform a gap analysis of current state to ideal state.
Performing a thorough search of available products that meet the standards for
the organization is the primary action you should take. Once the collated
information is obtained, convening a meeting with the key stakeholders
(nursing, medicine, finance, patient safety, legal, etc.) to determine the
organizational needs in relation to the intended financial impact and return on
investment may be required.
, Your hospital is considering implementing a robotic surgery program. As a
patient safety professional, you are concerned about the potential for patient
injury associated with this new technology. The most appropriate tool or
technique for assessing potential risks associated with implementation of the
new technology is:
A. Root cause analysis (RCA)
B. Patient safety leadership WalkRounds
C. Failure modes and effects analysis (FMEA)
D. Meaningful use evaluation - ANSWERS-C. Failure Modes and Effects
Analysis (FMEA)The best answer is FMEA.
FMEA is a prospective risk reduction strategy; ideally, it is used before a new
technology is implemented to determine how the new technology might fail and
cause harm. Patient safety leadership WalkRounds are designed to help leaders
gather facts about the care environment and create positive relationships
between staff and administration. Root cause analysis is a retrospective tool; it
is used after a harmful event or near miss to determine what went wrong.
Meaningful use evaluation is for evaluating the success of implementing an
electronic health record.
Your organization is preparing to change to a new electronic health record.
Many departments have been involved with the planning for this huge effort.
What would you suggest as part of the preparation strategy?
A. Offer to do a claims analysis for any related errors.
B. Suggest a Plan-Do-Study-Act (PDSA) cycle.
C. Conduct a failure modes and effects analysis (FMEA).
D. Conduct a root cause analysis (RCA). - ANSWERS-C. Conduct a failure
modes and effects analysis (FMEA).
FMEA would be valuable step for anticipating gaps in the planning so that
people can address potential problems before implementing the new system. A
