CPPS IHI TEST PAPER 2025/2026 QUESTIONS AND
SOLUTIONS MARKED A+
✔✔You are the charge nurse on a busy ICU. It is 11:00 PM, and one of your nurses
needs to leave for a family emergency. Which of the following actions is the most
appropriate next step?
A. Take on the nurse's patients for the rest of the shift.
B. Reassign the nurse's patients to the most senior nurse on the unit.
C. See if this is an established pattern for this nurse.
D. Call a huddle to reassign resources and establish a contingency plan. - ✔✔D. Call a
huddle to reassign resources and establish a contingency plan.
The best answer is to call a huddle, which is an appropriate option for ad hoc planning.
During the huddle, the team can reestablish situational awareness, confirm the plans
already in place, and assess the need to adjust the plan.An established pattern of
absenteeism is more of an HR issue than a patient safety issue. The pros and cons of
the other options, including the charge nurse taking on the patients (which would leave
the team without a leader) or the most senior nurse (who may already have the most
patients) taking on extra patient patients, can be discussed at the huddle.
✔✔The free, uninhibited flow of information that is open to the scrutiny of others is the
definition of:
A. Just Culture
B. Transparency
C. Quality care
D. High reliability - ✔✔B. Transparency
The Lucian Leape Institute defines transparency as the free, uninhibited flow of
information that is open to the scrutiny of others. The other three options would not be
so defined.
✔✔In cause analysis, the role of the Executive Sponsor is to:
A. Prepare for a visit by the department of health if the event meets criteria for reporting
to the state.
B. Complete the initial debrief following a patient safety event and ensure the safety of
all involved.
C. Coordinate all efforts of the cause analysis team and conduct performance
management discussions.
D. Help scope the objectives and maintain accountability for effective and timely action
plans. - ✔✔D. Help scope the objectives and maintain accountability for effective and
timely action plans.
Completing the initial debrief describes the role of the department manager or leader.
Preparing for a visit by the department of health is the responsibility of the regulatory
staff, and coordinating all efforts of the cause analysis team speaks to responsibilities of
,the cause analysis facilitator and department manager. The Executive Sponsor can help
establish the team charter, ensure adequate resources, and attend cause analysis
meetings as appropriate.
✔✔A medication error at a nearby hospital has recently received media attention. In
examining your own organization, you find similar processes are in place to the ones
that contributed to the error. You'd like to change your hospital's processes but worry
people will be resistant to change. What would be the best method to use to influence
others as to the need for change?
A. Reference accreditation standards and hospital policy as the need to make a change
in process.
B. Present the story in conjunction with your own facility's data.
C. Develop a staff recognition program for reporting actual events that occur in your
facility.
D. Conduct a root cause analysis on a similar event that has occurred at your own
facility. - ✔✔B. Present the story in conjunction with your own facility's data.
Effectively modifying behavior and developing acceptance of workplace changes
requires a multifaceted approach, and storytelling and quantitative analysis are
important aspects of effective calls to action. Some experts suggest that more than one
method of communication is necessary to be truly effective. The other answers
represent actions that could be taken depending on the specific issue; however,
providing a motivational story and your own facility's data would likely be most effective
in this scenario.
✔✔Your hospital's leadership is concerned about low safety culture survey scores in the
category of "communication openness." The percentage of positive responses related to
questioning someone with higher authority is well below national averages. The lead
patient safety professional has been asked to make recommendations on increasing the
questioning of those with higher authority.
To maximize risk reduction, when should staff be asked to stop and question a
situation?
A. When something doesn't seem right
B. When discrepancy has been confirmed
C. When a protocol was not followed
D. When patient harm is likely - ✔✔A. When something doesn't seem right.
A strong safety culture requires open communication and willingness by everyone in the
organization to speak up and question conditions and behaviors before they lead to an
event. Questioning a situation as soon as something doesn't seem right provides the
greatest risk reduction, and any limitation or restrictions on this type of questioning
erodes safety. If the expectation is to speak up only when there is a situation of potential
harm or procedural violation, there will be missed opportunities.
✔✔Hospital leadership has just learned of the reoccurrence of a type of sentinel event
that has not occurred in a long time, which they believed to have been permanently
, resolved. Which of the following possible explanations for the recurrence seems most
likely?
A. Staff are not familiar with safety policies and protocols due to significant turnover.
B. Leadership has stopped messaging on safety because significant time has passed
since the last sentinel event.
C. Negative changes in culture have reduced event reporting.
D. Drift to old habits over time has slowly eroded safer practice. - ✔✔B. Leadership has
stopped messaging on safety because significant time has passed since the last
sentinel event.
The most likely explanation is that leadership has not maintained a strong enough focus
on safety. With continued leadership attention on safety, drift to old habits should not be
occurring, and staff turnover should not be impacting safety. (Note that safety policies
and protocols are not safeguards against harm in and of themselves.) Sentinel events
are typically significant enough that they would be noticed even in the absence of a
strong reporting culture.v
✔✔You are charged with identifying and recommending a new event reporting system
for your organization. Which of the following would be the best technique to use when
evaluating new software systems?
A. Invite senior leaders of the organization to a workshop to ask questions of the
software vendor. Review leader evaluations following the workshop.
B. Develop a "Request for Proposal" to submit to various software vendors. Evaluate
the best responses to make a recommendation.
C. Conduct an open vendor fair for all staff to review various options. Evaluate written
and verbal feedback on the systems from participants.
D. Survey your peers across the nation to determine the most popular vendor.
Recommend the vendor that is referenced most frequently. - ✔✔C. Conduct an open
vendor fair for all staff to review various options. Evaluate written and verbal feedback
on the systems from participants.
The most successful and sustainable changes to organizational structure are developed
through a grassroots approach to leadership and workflow design. This has been
demonstrated with multiple workplace changes, but particularly with the implementation
of new reporting systems.With regard to the other possible answers: Senior leaders
should be involved with the decision-making process but should not necessarily provide
exclusive input on the decision. The "Request for Proposal" may be an important part of
an organization's evaluation process but should not be the sole input into the
recommendation process. Finally, conducting benchmark evaluations can be helpful,
but the simple tally described is too simplistic to determine a software recommendation.
✔✔You have been asked to present an overview of safety events to your hospital's
board of trustees. In order to best represent safety issues, you should:
A. Lead an open discussion of board members' safety concerns and recommendations.
B. Display a graph of the numbers and types of safety events reported in the past year.
C. Present cases of harm with contributing root causes and actions taken.
SOLUTIONS MARKED A+
✔✔You are the charge nurse on a busy ICU. It is 11:00 PM, and one of your nurses
needs to leave for a family emergency. Which of the following actions is the most
appropriate next step?
A. Take on the nurse's patients for the rest of the shift.
B. Reassign the nurse's patients to the most senior nurse on the unit.
C. See if this is an established pattern for this nurse.
D. Call a huddle to reassign resources and establish a contingency plan. - ✔✔D. Call a
huddle to reassign resources and establish a contingency plan.
The best answer is to call a huddle, which is an appropriate option for ad hoc planning.
During the huddle, the team can reestablish situational awareness, confirm the plans
already in place, and assess the need to adjust the plan.An established pattern of
absenteeism is more of an HR issue than a patient safety issue. The pros and cons of
the other options, including the charge nurse taking on the patients (which would leave
the team without a leader) or the most senior nurse (who may already have the most
patients) taking on extra patient patients, can be discussed at the huddle.
✔✔The free, uninhibited flow of information that is open to the scrutiny of others is the
definition of:
A. Just Culture
B. Transparency
C. Quality care
D. High reliability - ✔✔B. Transparency
The Lucian Leape Institute defines transparency as the free, uninhibited flow of
information that is open to the scrutiny of others. The other three options would not be
so defined.
✔✔In cause analysis, the role of the Executive Sponsor is to:
A. Prepare for a visit by the department of health if the event meets criteria for reporting
to the state.
B. Complete the initial debrief following a patient safety event and ensure the safety of
all involved.
C. Coordinate all efforts of the cause analysis team and conduct performance
management discussions.
D. Help scope the objectives and maintain accountability for effective and timely action
plans. - ✔✔D. Help scope the objectives and maintain accountability for effective and
timely action plans.
Completing the initial debrief describes the role of the department manager or leader.
Preparing for a visit by the department of health is the responsibility of the regulatory
staff, and coordinating all efforts of the cause analysis team speaks to responsibilities of
,the cause analysis facilitator and department manager. The Executive Sponsor can help
establish the team charter, ensure adequate resources, and attend cause analysis
meetings as appropriate.
✔✔A medication error at a nearby hospital has recently received media attention. In
examining your own organization, you find similar processes are in place to the ones
that contributed to the error. You'd like to change your hospital's processes but worry
people will be resistant to change. What would be the best method to use to influence
others as to the need for change?
A. Reference accreditation standards and hospital policy as the need to make a change
in process.
B. Present the story in conjunction with your own facility's data.
C. Develop a staff recognition program for reporting actual events that occur in your
facility.
D. Conduct a root cause analysis on a similar event that has occurred at your own
facility. - ✔✔B. Present the story in conjunction with your own facility's data.
Effectively modifying behavior and developing acceptance of workplace changes
requires a multifaceted approach, and storytelling and quantitative analysis are
important aspects of effective calls to action. Some experts suggest that more than one
method of communication is necessary to be truly effective. The other answers
represent actions that could be taken depending on the specific issue; however,
providing a motivational story and your own facility's data would likely be most effective
in this scenario.
✔✔Your hospital's leadership is concerned about low safety culture survey scores in the
category of "communication openness." The percentage of positive responses related to
questioning someone with higher authority is well below national averages. The lead
patient safety professional has been asked to make recommendations on increasing the
questioning of those with higher authority.
To maximize risk reduction, when should staff be asked to stop and question a
situation?
A. When something doesn't seem right
B. When discrepancy has been confirmed
C. When a protocol was not followed
D. When patient harm is likely - ✔✔A. When something doesn't seem right.
A strong safety culture requires open communication and willingness by everyone in the
organization to speak up and question conditions and behaviors before they lead to an
event. Questioning a situation as soon as something doesn't seem right provides the
greatest risk reduction, and any limitation or restrictions on this type of questioning
erodes safety. If the expectation is to speak up only when there is a situation of potential
harm or procedural violation, there will be missed opportunities.
✔✔Hospital leadership has just learned of the reoccurrence of a type of sentinel event
that has not occurred in a long time, which they believed to have been permanently
, resolved. Which of the following possible explanations for the recurrence seems most
likely?
A. Staff are not familiar with safety policies and protocols due to significant turnover.
B. Leadership has stopped messaging on safety because significant time has passed
since the last sentinel event.
C. Negative changes in culture have reduced event reporting.
D. Drift to old habits over time has slowly eroded safer practice. - ✔✔B. Leadership has
stopped messaging on safety because significant time has passed since the last
sentinel event.
The most likely explanation is that leadership has not maintained a strong enough focus
on safety. With continued leadership attention on safety, drift to old habits should not be
occurring, and staff turnover should not be impacting safety. (Note that safety policies
and protocols are not safeguards against harm in and of themselves.) Sentinel events
are typically significant enough that they would be noticed even in the absence of a
strong reporting culture.v
✔✔You are charged with identifying and recommending a new event reporting system
for your organization. Which of the following would be the best technique to use when
evaluating new software systems?
A. Invite senior leaders of the organization to a workshop to ask questions of the
software vendor. Review leader evaluations following the workshop.
B. Develop a "Request for Proposal" to submit to various software vendors. Evaluate
the best responses to make a recommendation.
C. Conduct an open vendor fair for all staff to review various options. Evaluate written
and verbal feedback on the systems from participants.
D. Survey your peers across the nation to determine the most popular vendor.
Recommend the vendor that is referenced most frequently. - ✔✔C. Conduct an open
vendor fair for all staff to review various options. Evaluate written and verbal feedback
on the systems from participants.
The most successful and sustainable changes to organizational structure are developed
through a grassroots approach to leadership and workflow design. This has been
demonstrated with multiple workplace changes, but particularly with the implementation
of new reporting systems.With regard to the other possible answers: Senior leaders
should be involved with the decision-making process but should not necessarily provide
exclusive input on the decision. The "Request for Proposal" may be an important part of
an organization's evaluation process but should not be the sole input into the
recommendation process. Finally, conducting benchmark evaluations can be helpful,
but the simple tally described is too simplistic to determine a software recommendation.
✔✔You have been asked to present an overview of safety events to your hospital's
board of trustees. In order to best represent safety issues, you should:
A. Lead an open discussion of board members' safety concerns and recommendations.
B. Display a graph of the numbers and types of safety events reported in the past year.
C. Present cases of harm with contributing root causes and actions taken.
