CPPS IHI PRACTICE EXAM QUESTIONS
WITH COMPLETE SOLUTIONS!!
1 of 126
Term
Of the following steps, which should be done first when conducting an
FMEA?
Identify a high-risk process to evaluate.
Formulate solutions for a high-risk process.
Develop a ranking method to prioritize actions.
Facilitate error management strategies.
Give this one a try later!
, B. perform a substitution test. D. use of color-coded labels that
are readily seen by staff
C. Patient feedback is used A. Identify a high-risk process
to redesign care processes. to evaluate.
Don't know?
2 of 126
Term
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.
Give this one a try later!
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
PDSA cycle would be a good way to test and implement any changes, but it
wouldn't help diagnose problems.
, 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.
A. Identify RCA team members.
The first step in an RCA is to form the team, which then gathers the appropriate
information, identifies factors contributing to the event, and interviews staff
members involved.
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 determine fair consequences for blameworthy events — this
makes the fourth answer the best.
Don't know?
, 3 of 126
Term
Why is it important to share lessons learned from RCAs?
A. It allows others to introduce workarounds to avoid the same
situation.
B.It exposes the fallibility of the clinician(s) involved.
C. Sharing these events should not be encouraged because it
increases the risk of litigation.
D.It allows co-workers to learn the rationale for why an event
occurred and incorporate new lessons learned into practice.
Give this one a try later!
D. It allows co-workers to learn the rationale for why an event occurred
and incorporate new lessons learned into practice.
Sharing allows others to adopt new methods and to heighten risk
awareness. In regard to the other possible answers: The goal of an RCA is
not to place blame on individual clinicians, and workarounds are oftentimes
unsafe practices that ignore systems issues that require fixing. Sharing
lessons learned from an RCA may decrease the risk of litigation by
improving patient safety and reducing the likelihood of an adverse event
occurring again.
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 punitive
response to safety
culture results; acknowledging high performers is important, but in isolation is
unlikely to drive change in other areas; and, lastly, organizations most likely do
not have the bandwidth to perform RCAs on underperforming units, and doing
so would be a misuse of root cause analysis tools.
WITH COMPLETE SOLUTIONS!!
1 of 126
Term
Of the following steps, which should be done first when conducting an
FMEA?
Identify a high-risk process to evaluate.
Formulate solutions for a high-risk process.
Develop a ranking method to prioritize actions.
Facilitate error management strategies.
Give this one a try later!
, B. perform a substitution test. D. use of color-coded labels that
are readily seen by staff
C. Patient feedback is used A. Identify a high-risk process
to redesign care processes. to evaluate.
Don't know?
2 of 126
Term
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.
Give this one a try later!
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
PDSA cycle would be a good way to test and implement any changes, but it
wouldn't help diagnose problems.
, 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.
A. Identify RCA team members.
The first step in an RCA is to form the team, which then gathers the appropriate
information, identifies factors contributing to the event, and interviews staff
members involved.
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 determine fair consequences for blameworthy events — this
makes the fourth answer the best.
Don't know?
, 3 of 126
Term
Why is it important to share lessons learned from RCAs?
A. It allows others to introduce workarounds to avoid the same
situation.
B.It exposes the fallibility of the clinician(s) involved.
C. Sharing these events should not be encouraged because it
increases the risk of litigation.
D.It allows co-workers to learn the rationale for why an event
occurred and incorporate new lessons learned into practice.
Give this one a try later!
D. It allows co-workers to learn the rationale for why an event occurred
and incorporate new lessons learned into practice.
Sharing allows others to adopt new methods and to heighten risk
awareness. In regard to the other possible answers: The goal of an RCA is
not to place blame on individual clinicians, and workarounds are oftentimes
unsafe practices that ignore systems issues that require fixing. Sharing
lessons learned from an RCA may decrease the risk of litigation by
improving patient safety and reducing the likelihood of an adverse event
occurring again.
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 punitive
response to safety
culture results; acknowledging high performers is important, but in isolation is
unlikely to drive change in other areas; and, lastly, organizations most likely do
not have the bandwidth to perform RCAs on underperforming units, and doing
so would be a misuse of root cause analysis tools.
