CPPS Exam 2023 with complete solutions

Retrospective Integration - ANSWER-Designing education-based strategies to mitigate identified risks Clinical transformation care that is consistently (6 things).... - ANSWER-Safe. Effective. Patient Centered. Timely. Efficient. Equitable. Safety - ANSWER-Prevention/moderation of hazard (induced harm) Unsafe Acts - ANSWER-An act that is not safe for an employee. Human error. (slips, lapses, mistakes, violations) The Safety Assessment Code (SAC) Matrix - ANSWER-When a severity category is paired with probability category - a ranked matrix score results. Ranks can be used for analysis and deciding who needs to be notified about the event. Errors can occure because of 2 types of failures... - ANSWER-1.) Action did not go as intended. 2.) intended action was wrong PDSA Cycle - ANSWER-Plan, Do, Study, Act. Shorthand for testing a change. Going through the 4 steps guides the thinking process. Breaks down the task and then allows evaluation of the outcome, improving it and testing again. Development Philosophy - ANSWER-Education based (10%) - training, workshops Relationship based (20%) - Role models, coaching Experience based (30%) - Development in role Strategies to error-proof high-risk transitions...(2) - ANSWER-Improve handoffs in care Medication reconciliation Model for Improvement - 3 fundamental questions organizations must address for each process being improved - ANSWER-1.) How will we know that a change is an improvement? 2.) What changes can we make that will result in an improvement? 3.) What are we trying to accomplish? Behaviors that undermine a culture of safety... - ANSWER-1.) interfere with ability to achieve intended outcomes 2.) threaten safety 3.) violate policies 4.) create unsafe environment Lean Management Method (Toyota Production) - ANSWER-Creates smooth patient workflows Eliminates wast in time/effort/resources Provides services patients find valuable Aims to continuous increase operational processes to achieve quality services and promote productive culture A particularly effective system lacks standardization & waste (very common) Sharp end - ANSWER-The individuals and part of the healthcare system in direct contact with patients Corresponds with errors from "active failures" Blunt end - ANSWER-Refers to layers of the healthcare system not in direct contact with patients Influences the "sharp end" Refers to those who set policy, manage, design equipment...etc. Root of Medical Error - ANSWER-Sharp end vs. blunt end. Picture a triangle. Top = sharp end. bottom = blunt. Sharp end has causes going towards it, as blunt end has investigations. Mistake - ANSWER-Category of error Failures during intentional behaviors or incorrect choices typically involving insufficient knowledge ex: failure of planning Rule Based Mistake - ANSWER-Wrong-rule applied, wrong diagnosis Knowledge Based Management - ANSWER-Did not take correct cause of action, new clinical situation Knowledge Based Mistake - ANSWER-Did not take correct cause of action, new clinical situation Slip - ANSWER-Category of error schematic breakdown occur in the face of competing distractions ex: selecting wrong med from an automated med list Overconfidence Bias - ANSWER-The tendency to believe we know more than we do Availability Bias - ANSWER-The tendency to assume when judging possibilities that the first possibility is selected as the most likely to be possible. Acts as a cognitive short cut in the setting of a complex situation Confirmation Bias - ANSWER-Tendency to focus on evidence that supports a working hypothesis without looking for further info that may refute the original hypothesis Oversimplification of Causality - ANSWER-Application of past events leads to underestimation of future consequences Missed Care (Misscare) - ANSWER-Essential or necessary nursing care that didn't get done Diminishing joy & Meaning Correlation between teamwork & missed RN care Prospective Integration - ANSWER-Using sim-based learning experiences to identify human factor hazards Debrief Make it a part of the culture Patient Family Advisory Council (PFAC) - ANSWER-Provides framwork Ensures patient's perspective Patient's experience Empowers the public with info System - ANSWER-Composite of people, procedures & equipment that are integrated to perform a specific operational task Teamwork training principles - ANSWER-Appropriate assertiveness Briefing Close-loop communication Situation awareness What factors affect patient's willingness to take action? - ANSWER-Gravity of threat perceived (not that sick...) Effectiveness of action (med won't work...) Consequences of speaking up (get worse if say something...) Self-efficacy (treatment already worked....) Staff members instructions/expectations (got all the info they need...) Heirarchy of Reliability - ANSWER-Forcing functions Computerization Standardization Double Checks Policies Education Human Factors Engineering - ANSWER-Focuses on human beings & their interactions with each other, and with products Don't try to change human condition, try to change the conditions under which humans work Just Culture - ANSWER-Front line personnel are comfortable disclosing errors Maintain professional accountability Non-punitive for system failings Does not tolerate gross misconduct Flight Simulator - ANSWER-Adapted by Leapfrog group Measuring the effective use of EHR after implementation CPOE, BCMA Model of Error Causation - ANSWER-Swiss cheese model Principle behind layered security Create multiple layers to ensure unsafe things cannot get through Don't rely on human perfection; need for system fixes Evaluation Model - 3 phases of Health IT analysis - ANSWER-Planning for new/replacement systems Health It implementation Ongoing system use & evaluation IHI Global tool - ANSWER-Tool provides instructions for conducting retrospective reviews of inpatient records using triggers to identify possible adverse events Failure Modes & Effective Analysis (FMEAs) - ANSWER-Procedure for analysis of potential failure modes within a system Classification by severity & likelihood of the failures Effective in identifying safety concerns with products & implementation plans System Safety - ANSWER-Formal disciplined approach to hazards Reliability in a system - ANSWER-It's ability to perform its function over time under commonly occurring conditions Components of a system - ANSWER-Interconnected in such a manner to perform a function Input is provided from a source such as another component or human Human Factors - ANSWER-Discovers and applies information about human behavior, abilities, limitations, and other characteristics to the design and evaluation of products, systems, jobs, tools, and environments for enhancing productive, safe, and comfortable human use. Safety Leader - ANSWER-Helps organization to elimination/control hazards Common Health IT Problems - Human/Computer - ANSWER-Patient not identified properly info entered in wrong medical record Data entered wrong due to multiple records open System failed to alert user of flag/pop-up User ignored/overrode an alert Data incomplete/missing Common Health IT Problems - Computer/Computer - ANSWER-Data not displaying Network slow Interface issues Software not up to date Data was lost Human Factors: SRK Model - ANSWER-Skills Based = automated routines; requires little conscious attention Rule Based = protocolized behavior; process, procedure Knowledge Based = improvisation in unfamiliar environment; Don't know routines/rules Forcing Functions - ANSWER-Aspect of design that prevents user from taking an action without consciously considering information relevant to that action ex: Parents hitting kids in 70-80s; changed brake systems in cars. Now have to brake to change gears Hazards - ANSWER-Conditions or activities in a system that pose a threat of harm They get in the way of reliability SAC Matrix Severity Categories - ANSWER-Catastrophic Major Moderate Minor SAC Matrix Probability Categories - ANSWER-Frequent Occasional Uncommon Remote To Err is Human - ANSWER-First report to bring patient safety to forefront Essential elements to promote liability - ANSWER-People = committed leadership, project champs, teams Process = policies, clear goals, sufficient resources Systems = tools, metrics, data, review process Rules of Causation - ANSWER-Cause & Effect Human error must have a preceding cause Failure to follow procedure by itself is not a root cause Negative descriptors aren't actionable Failure to act is not a cause Measurability - ANSWER-Tendency to focus on what we can measure Easier for clinicians/patients to see Easier for policy makers to build incentive programs Authority Gradient - ANSWER-The balance of decision-making power or the steepness of command hierarchy in a given healthcare team. Low man on totem pole won't speak up to powered individual. RCA2 Elements (7) - ANSWER-1. Risk-based prioritization 2. Non-punitive 3. Timely & Teamwork