1|Page
CPPS REVIEW COURSE WITH AND
ANSWERS 100% VERIFIED
Which of the following concepts best explains what happened?
A.) Normalized deviance
B.) Malicious intent
C.) Workarounds
D.) Checklist fatigue - correct answer_ A.) Normalized deviance
Normalized deviance refers to the phenomena in which workarounds
become accepted as the norm. (Workarounds are deviations from the
standard process that usually happen because the process is in some
way flawed, e.g., in this case, maybe two people were required to count
but there weren't always two people available.) Malicious intent is
highly unlikely to be the cause here. Checklist fatigue may lead to
workarounds, but that does not appear to be what happened here.
The requirement to perform manual independent double checks (IDCs)
to reduce errors in the administration of high-alert medications is
common in US hospitals. The Institute for Safe Medication Practices
(ISMP) recommends that IDC be used judiciously and for only very
selective tasks, not for all high-alert medications.
The rationale for ISMP's recommendation is:
,2|Page
A.) Given the workload requirements in today's hospitals, staff
members do not have adequate time to perform IDC for all high-alert
medications.
B.) Research has demonstrated that IDCs are not effective.
C.) Hospitals have reversal agents available to treat most accidental
medication overdose
D.) The advent of computerized prescriber order entry (CPOE) systems
has reduced the potential for hospital medication errors to a negligible
level. - correct answer_ A.) Given the workload requirements in today's
hospitals, staff members do not have adequate time to perform IDC for
all high-alert medications.
According to ISMP, correctly double-checking all high-alert medications
could add 20 minutes to the nurse's day, a workload that most
organizations would not find sustainable.In regard to the other answer
options: While hospitals do have reversal agents, a far better practice is
to prevent the error in the first place. CPOE systems have prevented
many errors, but many errors remain. Research has demonstrated that
IDC done correctly is effective, but IDC is most often not done correctly.
A nurse is preparing to take medication to Patient A. On the way to
Patient A's room, Patient B calls out for immediate assistance. The
nurse goes to assist Patient B. After helping Patient B, the nurse gives
Patient B the medication intended for Patient A.
This scenario is most clearly an example of which of the following?
,3|Page
A.) Sentinel event
B.) Human error
C.) Behavioral choice
D.) System failure - correct answer_ B.) Human error
Giving a medication to the wrong patient when distracted is a human
error. The nurse did not make a behavioral choice and the system did
not fail. A sentinel event occurs if death or major permanent loss of
function occurs.
The patient safety team reviewed a sample of patients who had been
readmitted within 48 hours of discharge and noticed that a patient's
discharge medication lists had not been accurately reconciled. The
appropriate next steps for the team to take include:
A.) Gather data on the accuracy and timeliness of medication
reconciliation.
B.) Ask nursing to be responsible for all medication reconciliation.
C.) Reprimand the discharging provider.
D.) Gather a team of key stakeholders to create a flow map for the
medication reconciliation process. - correct answer_ A.) Gather data on
the accuracy and timeliness of medication reconciliation.
Logically, it would be valuable to validate there's a real problem by
gathering more data before assembling a group to work on the issue. If
, 4|Page
there is a problem with reliability of this process, a good next step
would be to map the process to look for defects or efficiency barriers.
A known barrier to patient safety is staff not speaking up when they are
concerned or if they see safety violations. Which of the following is the
best approach to help foster a culture that supports speaking up?
A.) Putting up posters around the organization that reinforce speaking
up as a safety strategy
B.) Implementing Just Culture tools
C.) Using trends in event reporting to identify staff who don't speak up
D.) Using culture of safety data to assist low-performing departments
with defining strategies for improvement - correct answer_ D.) Using
culture of safety data to assist low-performing departments with
defining strategies for improvement
Using culture of safety data to target departments that are contributing
the most to the problem can help build momentum for speaking up
across the organization. The Safety Attitudes Questionnaire (SAQ),
which specifically asks questions about how well people are
encouraged to speak up and about feedback loops, could point to
departments most in need of help. Adopting just culture is not an
incorrect answer to the question, but using culture of safety data is a
more targeted answer.
CPPS REVIEW COURSE WITH AND
ANSWERS 100% VERIFIED
Which of the following concepts best explains what happened?
A.) Normalized deviance
B.) Malicious intent
C.) Workarounds
D.) Checklist fatigue - correct answer_ A.) Normalized deviance
Normalized deviance refers to the phenomena in which workarounds
become accepted as the norm. (Workarounds are deviations from the
standard process that usually happen because the process is in some
way flawed, e.g., in this case, maybe two people were required to count
but there weren't always two people available.) Malicious intent is
highly unlikely to be the cause here. Checklist fatigue may lead to
workarounds, but that does not appear to be what happened here.
The requirement to perform manual independent double checks (IDCs)
to reduce errors in the administration of high-alert medications is
common in US hospitals. The Institute for Safe Medication Practices
(ISMP) recommends that IDC be used judiciously and for only very
selective tasks, not for all high-alert medications.
The rationale for ISMP's recommendation is:
,2|Page
A.) Given the workload requirements in today's hospitals, staff
members do not have adequate time to perform IDC for all high-alert
medications.
B.) Research has demonstrated that IDCs are not effective.
C.) Hospitals have reversal agents available to treat most accidental
medication overdose
D.) The advent of computerized prescriber order entry (CPOE) systems
has reduced the potential for hospital medication errors to a negligible
level. - correct answer_ A.) Given the workload requirements in today's
hospitals, staff members do not have adequate time to perform IDC for
all high-alert medications.
According to ISMP, correctly double-checking all high-alert medications
could add 20 minutes to the nurse's day, a workload that most
organizations would not find sustainable.In regard to the other answer
options: While hospitals do have reversal agents, a far better practice is
to prevent the error in the first place. CPOE systems have prevented
many errors, but many errors remain. Research has demonstrated that
IDC done correctly is effective, but IDC is most often not done correctly.
A nurse is preparing to take medication to Patient A. On the way to
Patient A's room, Patient B calls out for immediate assistance. The
nurse goes to assist Patient B. After helping Patient B, the nurse gives
Patient B the medication intended for Patient A.
This scenario is most clearly an example of which of the following?
,3|Page
A.) Sentinel event
B.) Human error
C.) Behavioral choice
D.) System failure - correct answer_ B.) Human error
Giving a medication to the wrong patient when distracted is a human
error. The nurse did not make a behavioral choice and the system did
not fail. A sentinel event occurs if death or major permanent loss of
function occurs.
The patient safety team reviewed a sample of patients who had been
readmitted within 48 hours of discharge and noticed that a patient's
discharge medication lists had not been accurately reconciled. The
appropriate next steps for the team to take include:
A.) Gather data on the accuracy and timeliness of medication
reconciliation.
B.) Ask nursing to be responsible for all medication reconciliation.
C.) Reprimand the discharging provider.
D.) Gather a team of key stakeholders to create a flow map for the
medication reconciliation process. - correct answer_ A.) Gather data on
the accuracy and timeliness of medication reconciliation.
Logically, it would be valuable to validate there's a real problem by
gathering more data before assembling a group to work on the issue. If
, 4|Page
there is a problem with reliability of this process, a good next step
would be to map the process to look for defects or efficiency barriers.
A known barrier to patient safety is staff not speaking up when they are
concerned or if they see safety violations. Which of the following is the
best approach to help foster a culture that supports speaking up?
A.) Putting up posters around the organization that reinforce speaking
up as a safety strategy
B.) Implementing Just Culture tools
C.) Using trends in event reporting to identify staff who don't speak up
D.) Using culture of safety data to assist low-performing departments
with defining strategies for improvement - correct answer_ D.) Using
culture of safety data to assist low-performing departments with
defining strategies for improvement
Using culture of safety data to target departments that are contributing
the most to the problem can help build momentum for speaking up
across the organization. The Safety Attitudes Questionnaire (SAQ),
which specifically asks questions about how well people are
encouraged to speak up and about feedback loops, could point to
departments most in need of help. Adopting just culture is not an
incorrect answer to the question, but using culture of safety data is a
more targeted answer.
