CPPS Review Course exam questions and answers

A staff member discovered a medication with an incorrect label. The staff immediately notified the pharmacist and the correct label was sent prior to medication administration. Then, the staff completed an event report through the organization's reporting tool. Which of the following actions should the unit manager take in response to this event? A.) Document the incident in the employee's performance review. B.) Investigate system failures and recognize the employee for reporting a near-miss event. C.) Notify the director of pharmacy about the pharmacist's error. D.) No action, since the incident did not cause patient harm. B.) Investigate system failures and recognize the employee for reporting a near-miss event. You are educating clinical managers in your health care facility on how to identify appropriate events for conducting a root cause analysis (RCA). Which event provides the BEST opportunity for an RCA? A.) A post-operative patient removes his own IV, causing a skin tear from the tape. B.) A patient with no known allergies experiences an anaphylactic reaction to an antibiotic, requiring transfer to ICU. C.) The biopsy samples from a colonoscopy are never received by pathology after the procedure. D.) In the last four months, there have been three occurrences of depressed respirations related to sedation in the same department. C.) The biopsy samples from a colonoscopy are never received by pathology after the procedure. A hospital is using the AHRQ Hospital Survey on Patient Safety Culture. There were 80 employees who responded. Responses to the survey item that states "we have patient safety problems in this unit" were as follows: Strongly Agree: 16 Agree: 32 Neither Agree nor Disagree: 12 Disagree: 17 Strongly Disagree: 3 A.) 75% B.) 60% C.) 25% D.) 20% C.) 25%The AHRQ Hospital Survey on Patient Safety Culture User Guide scoring guidance says to use the "Strongly Agree/Agree" response sum, or, for negatively worded items—such as this one—use the "Strongly Disagree/Disagree" sum. In this example, 17+3 gives us the response sum (i.e., 20), which we divide by total number of respondents (i.e., 80): 20/80 = 25%. What is one example of a communication technique providers can use to improve communication with patients? A.) SBAR B.) Teach-back C.) CUSP D.) Two-Challenge Rule B.) Teach-back The Impact of Organizational Change on Safety What are the three steps to managing patient safety through organizational change? A.) Monitor change, identify potential safety implications, and employ countermeasures to mitigate any anticipated risks B.) Employ countermeasures to mitigate any anticipated risks, monitor change C.) Identify potential safety implications, employ countermeasures to mitigate any anticipated risks, and monitor the change D.) None of the above C.) Identify potential safety implications, employ countermeasures to mitigate any anticipated risks, and monitor the change What is the term which describes the belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes? Psychological safety A safety-supportive system of shared accountability in which: 1.) Healthcare institutions are accountable for safe systems design and for encouraging safe choices of clinicians and staff (clear expectations set the tone to create environment of mutual respect) 2.) Clinicians and staff are accountable for the quality of their choices (i.e. striving to make the best possible choices as professionals) Just Culture At the conclusion of a surgical procedure at your hospital, the instrument count is incorrect. The hospital policy does not stipulate that the surgeon must remain on the premises until an x-ray is obtained to check for retained foreign objects. By the time the x-ray results come in to reveal that there is, in fact, a retained instrument, the original surgeon has left the hospital to catch a flight. Another surgeon is contacted to remove the retained instrument. How should leadership respond to this event? A.) Revise the hospital policy to make it clear that surgeons must stay in the operating room (OR) until instrument count issues are resolved. B.) Using an appropriate accountability system, counsel the surgeon about customary clinical standards. C.) Re-educate the OR nursing staff on keeping track of instruments on the sterile field. D.) Create a process map of how instruments are managed during surgery, looking for latent flaws. B.) Using an appropriate accountability system, counsel the surgeon about customary clinical standards. This term reflects a group of individuals who understand the importance of self- and group- regulation. Professionalism The human resources department at your organization has asked your patient safety specialist for recommendations on new policies to help support safety culture. Which recommendation sounds best? A.) Sending human resources all event data so that they can record involvement in adverse events in personnel files B.) Including human resources in all root cause analyses so that they can provide guidance on recommended training updates for staff C.) Implementing routine use of a tool to determine which events are attributed to human error, at-risk behavior, and reckless behavior D.) 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 D.) 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 At the end of a long, exhausting shift, an experienced nurse administered the wrong medication by picking up the wrong syringe. The wrong medication was an analgesic, and the patient didn't suffer any problems. After recalling that his colleague was fired last month over a medication error, he decides not to file an incident report. Safety culture would be improved if the hospital provided this employee with which of the following? A.) Situational awareness training B.) Training on reporting C.) Psychological safety D.) An electronic reporting system C.) Psychological safety A staff nurse at your hospital fails to complete a double-check before administering a high-alert medication. She gives the medication to the incorrect patient, and the patient suffers an arrhythmia. When applying James Reason's unsafe acts algorithm, what is a strategy to use prior to holding the nurse personally accountable? A.) Perform the substitution test with three other nurses. B.) Have the chief nursing officer interview with the nurse. C.) Hold a root cause analysis. D.) Ask other nurses if the staff nurse is trustworthy. A.) Perform the substitution test with three other nurses. To improve culture of safety survey results, which of the following should an organization do? A.) Acknowledge and celebrate high-performing areas in front of leadership. B.) Perform root cause analysis on underperforming units to better understand their results. C.) Examine high-performing units to identify and disseminate best practices. D.) Offer coaching and apply Just Culture principles to leaders in lower performing areas. C.) Examine high-performing units to identify and disseminate best practices. In which of the following activities would a patient safety specialist engage to promote a culture of safety? A.) Instruct team members to act in a safe and respectful manner. B.) Focus on a list of projects identified by senior stakeholders. C.) Review annual data on defects and successes. D.) Apply best evidence with the goal of failure-free operation over time. D.) Apply best evidence with the goal of failure-free operation over time. As your organization's patient safety officer, you are reviewing unit results on the AHRQ Culture of Safety Survey. You are speaking with the manager of a unit for which the unit percent positive score is 30 percent for the following statement: "Staff in this unit work longer hours than is best for patient care." What do you tell the manager the positive answer in this statement means? A.) 30% of the staff agree with the statement. B.) 30% of the staff work longer hours. C.) 30% of the staff disagree with the statement. D.) 70% of the staff work longer hours. C.) 30% of the staff disagree with the statement. The Just Culture model includes creating a learning culture, designing safe systems, and which of the following activities? A.) Providing punishment equal to the harm caused B.) Decreasing the amount of reported errors C.) Finding the individual to blame D.) Managing behavioral choices D.) Managing behavioral choices Which of the following is the best first step in changing the culture of safety in a health care organization? A.) Conduct an assessment and gather focused data. B.) Develop, policies, procedures, and checklists for safety. C.) Hire an experienced patient safety officer with a strong performance record. D.) Implement communication and teamwork tools. A.) Conduct an assessment and gather focused data. A nurse on a medical-surgical unit does not comply with the barcode medication administration (BCMA) procedure while caring for one of her patients. Her supervisor is deciding how to respond. As her supervisor, what would you do? A.) Ask the nurse what was occurring at the time, and why she chose to bypass the policy. B.) Counsel the nurse on the importance of following policy C.) Ask staff if there are adequate scanners to meet their needs. D.) Request that the pharmacy run a report of the BCMA compliance rates of the unit. A.) Ask the nurse what was occurring at the time, and why she chose to bypass the policy. What are the 3 key areas of Patient Safety leadership? Strategy, Operations, and Engagement When setting organizational safety priorities, it is best to: A.) Review the current literature to identify areas of frequent concern. B.) Focus primarily on accreditation standards and requirements. C.) Determine priorities based on pay-for-performance measurements. D.) Develop a mechanism to gather input from a variety of sources. D.) Develop a mechanism to gather input from a variety of sources. A hospital is attempting to engage the board in their quality endeavors. Which is the best strategy to improve the board's involvement? A.) Focus only on measures that are tied to reimbursement. B.) Report all quality measures to the board. C.) Align the quality measures with the hospital's strategic goals. D.) Set only goals that can be attained. C.) Align the quality measures with the hospital's strategic goals. Which of the following is required to begin the journey to a culture of safety? A.) Care should depend on independent, individual performance excellence. B.) Accountability must be universal and reciprocal, not just top-down. C.) Care should be provider-centered rather than patient-centered. D.) RCA teams must look at errors as individual failures. B.) Accountability must be universal and reciprocal, not just top-down. You are meeting with your organization's CFO to review the likely Return on Investment (ROI) for several possible patient safety initiatives. Based only on the projected ROI, which project is most likely to receive the CFO's approval? A.) Implementation of Computerized Provider Order Entry to reduce the number of medication errors with an ROI of 1.0, or 100 percent. B.) Procurement of new beds with built-in alarms to reduce falls with an ROI of 0.9, or 90 percent. C.) Implementation of evidence-based guidelines to reduce the rate of catheter-associated urinary tract infections with an ROI of 3.0, or 300 percent. D.) Implementation of a sitter program, which has been shown to reduce falls and improve patient satisfaction with an ROI of 0.5, or 50 percent. C.) Implementation of evidence-based guidelines to reduce the rate of catheter-associated urinary tract infections with an ROI of 3.0, or 300 percent. The free, uninhibited flow of information that is open to the scrutiny of others is the definition of: A.) Quality care B.) Just Culture C.) Transparency D.) High reliability C.) Transparency When an adverse event occurs with a patient: A.) An investigation should commence to determine the staff member at fault. B.) The event should be openly discussed with the patient, family, and staff. C.) A root cause analysis should be completed and submitted to the Joint Commission. D.) The patient should not be told about the event because of the possibility of legal action. B.) The event should be openly discussed with the patient, family, and staff. Which of the following changes to operations would best highlight leadership's commitment to patient safety? A.) Executive leadership regularly participating in leadership rounds and daily safety briefings B.) The hospital executive reporting on patient safety at every board meeting C.) Implementing quarterly town hall meetings to share organizational information D.) Including an executive representative on all root cause analysis teams A.) Executive leadership regularly participating in leadership rounds and daily safety briefings Which of the following tactics is the best approach to increase near-miss event reporting? A.) Include staff names in event reports. B.) Give staff up to a week to report events. C.) Require staff to report all errors and near-misses. D.) Provide event reporters with feedback and follow-up D.) Provide event reporters with feedback and follow-up 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.) Conduct an open vendor fair for all staff to review various options. Evaluate written and verbal feedback on the systems from participants. C.) Survey your peers across the nation to determine the most popular vendor. Recommend the vendor that is referenced most frequently. D.) Develop a "Request for Proposal" to submit to various software vendors. Evaluate the best responses to make a recommendation. B.) Conduct an open vendor fair for all staff to review various options. Evaluate written and verbal feedback on the systems from participants. During daily rounding, a vice president observed a problem in a particular device that impacts delivery of care. He shared the information with other senior executive team members, and, upon further investigation, they learned that the issue was common. The findings resulted in the organization replacing the defective devices in all affected areas. Which of the following high-reliability principles did the leaders of this organization apply? A.) Deference to expertise B.) Sensitivity to operations C.) Resiliency D.) Reluctance to accept simple explanations B.) Sensitivity to operations A patient safety professional wants to ensure engagement of employees in a new patient safety initiative in the hospital. He should: A.) Use staff recommendations for workflow. B.) Collect data on previous initiatives. C.) Communicate the purpose of the initiative to the governing board. D.) Train staff on patient safety principles. A.) Use staff recommendations for workflow. 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. 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.) Present cases of harm with contributing root causes and actions taken. B.) Highlight system-wide improvements that have been implemented in the past year. C.) Lead an open discussion of board members' safety concerns and recommendations. D.) Display a graph of the numbers and types of safety events reported in the past year. A.) Present cases of harm with contributing root causes and actions taken. Your patient safety team performs a root cause analysis on a recent wrong-side surgery event. Which of the following action items reflects the highest level of reliability? A.) Change the color of surgical site markers from black to red. B.) Implement a process in which the surgical technician holds the scalpel (and does not hand it to the surgeon) until a timeout with all team members at attention has taken place. C.) Educate surgeons to be present for surgical timeouts. D.) Every month, perform multidisciplinary simulations empowering all staff to speak up for safety. B.) Implement a process in which the surgical technician holds the scalpel (and does not hand it to the surgeon) until a timeout with all team members at attention has taken place. 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 a protocol was not followed C.) When discrepancy has been confirmed D.) When patient harm is likely A.) When something doesn't seem right 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.) Negative changes in culture have reduced event reporting B.) Drift to old habits over time has slowly eroded safer practice. C.) Staff are not familiar with safety policies and protocols due to significant turnover. D.) Leadership has stopped messaging on safety because significant time has passed since the last sentinel event. D.) Leadership has stopped messaging on safety because significant time has passed since the last sentinel event. 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.) See if this is an established pattern for this nurse. B.) Take on the nurse's patients for the rest of the shift. C.) Reassign the nurse's patients to the most senior nurse on the unit. D.) Call a huddle to reassign resources and establish a contingency plan. D.) Call a huddle to reassign resources and establish a contingency plan.