CPPS Terms White Sheet UPDATED
ACTUAL Exam Questions and CORECT
Answers
Adverse drug event (adverse drug error, ADE) - CORRECT ANSWER -Any incident in
which the use of a medication (drug or biologic) at any dose, a medical device, or a special
nutritional product (e.g., dietary supplement, infant formula, medical food) may have resulted in
an adverse outcome in a patient. (JCAHO 2001); (2) An incident resulting from medical
intervention related to a drug. (Zipperer et al.)
Adverse drug reaction (ADR) - CORRECT ANSWER -An undesirable response
associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity, or
both. (JCAHO 2001)
Adverse sentinel event - CORRECT ANSWER -An unexpected occurrence involving
death or serious physical or psychological injury, or the risk thereof. Serious injury specifically
includes the loss of limb or function. (JCAHO 1996)
Automation failure (Safety Concern) - CORRECT ANSWER -Examples: equipment
should be fail safe, or alarms should signal; work around plans should be available to recover
from failures. (ESRD) --We should be able to react and respond to automation failures without
compromising patients.
Bad outcome - CORRECT ANSWER -Failure to achieve a desired outcome of care.
(Kohn et al.)
Benign errors - CORRECT ANSWER -Events which cause no harm or lack an adverse
outcome. Also referred to as precursor events or near misses. (Zipperer et al.)
Birth defects, miscarriage, stillbirth or birth with disease (Serious Adverse Reaction) -
CORRECT ANSWER -If exposure to a medical product before conception or during
pregnancy is suspected of causing an adverse outcome in the child. Examples: malformation in
the child caused by the acne drug Accutane, or isotretinoin. (Henkel FDA)
,Blunt end - CORRECT ANSWER -...where regulatory, administrative, and organizational
factors reside.... The blunt end of the system is the source of the resources and constraint that
form the environment where practitioners work. The blunt end is also the source of demands for
production that sharp end practitioners must meet. (Zipperer et al.)
Classification system - CORRECT ANSWER -The categorizing of errors into
distinguishing levels based on their behavior, accountability, outcome, context, or process.
(ESRD)
Cognitive science - CORRECT ANSWER -An amalgamation of disciplines including
artificial intelligence, neuroscience, philosophy, and psychology. Within cognitive science,
cognitive psychology is an umbrella discipline for those interested in cognitive activities such as
perception, learning, memory, language, concept formation, problem solving, and thinking.
(Zipperer et al.)
Communication behaviors that increase risk to patients in operating theatres - CORRECT
ANSWER -Failure to inform team of patient's problem (e.g., surgeon fails to inform
anesthetist of use of drug before blood pressure is seriously affected) and failure to discuss
alternative procedures. (Helmreich)
Communication breakdown related to treatment plan (Safety Concern) - CORRECT
ANSWER -Discrepancies in communication of treatment plan between caregiver and
patient, or between two caregivers. (ESRD)
Communications error - CORRECT ANSWER -(from aviation) Missing or wrong
information exchange or misinterpretation (e.g. misunderstood altitude clearance). (Helmreich)
Constraint and forcing strategies not available (Safety Concern) - CORRECT ANSWER -
There were no checkpoints or required steps that would force individuals to recognize the
pending mistake. Some activities can be engineered so that it is impossible to make a mistake
(e.g., it is impossible to attach an oxygen connector to the suction outlet because the connector is
designed to fit only the O2 outlet). (ESRD)
, Complication - CORRECT ANSWER -A detrimental patient condition that arises during
the process of providing health care, regardless of the setting in which the care is provided. For
instance, perforation, hemorrhage, bacteremia, and adverse reactions to medication (particularly
in the elderly) are four complications of colonoscopy and its associated anesthesia and sedation.
A complication may prolong an inpatient's length of stay or lead to other undesirable outcomes.
(JCAHO 2001)
Critical incident - CORRECT ANSWER -A human error or equipment failure that could
have lead (if not discovered or corrected in time) or did lead to an undesirable outcome, ranging
from increased length of hospital stay to death. (Zipperer et al.)
Critical incident technique - CORRECT ANSWER -A set of procedures for collecting
direct observations of human behavior in such a sway as to facilitate their potential usefulness in
solving practical problems and developing broad psychological principles. (Zipperer et al.)
Death (Serious Adverse Reaction) - CORRECT ANSWER -If an adverse reaction to a
medical product is a suspected cause of a patient's death. (Henkel FDA)
Decision error - CORRECT ANSWER -(from aviation) decision that unnecessarily
increases risk (e.g. unnecessary navigation through adverse weather). (Helmreich)
Disability (Serious Adverse Reaction) - CORRECT ANSWER -If the adverse reaction
caused a significant or permanent change in a patient's body function, physical activities, or
quality of life. Examples: strokes or nervous system disorders brought on by drug therapy.
(FDA)
Dose omission - CORRECT ANSWER -The failure to administer an ordered dose to a
patient before the next scheduled dose, if any. This excludes patients who refuse to take a
medication or a decision not to administer. (NCCMERP)
Environmental stressors (Safety Concern) - CORRECT ANSWER -Workload, workspace,
staffing, time pressures, noise, heat. (ESRD)
ACTUAL Exam Questions and CORECT
Answers
Adverse drug event (adverse drug error, ADE) - CORRECT ANSWER -Any incident in
which the use of a medication (drug or biologic) at any dose, a medical device, or a special
nutritional product (e.g., dietary supplement, infant formula, medical food) may have resulted in
an adverse outcome in a patient. (JCAHO 2001); (2) An incident resulting from medical
intervention related to a drug. (Zipperer et al.)
Adverse drug reaction (ADR) - CORRECT ANSWER -An undesirable response
associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity, or
both. (JCAHO 2001)
Adverse sentinel event - CORRECT ANSWER -An unexpected occurrence involving
death or serious physical or psychological injury, or the risk thereof. Serious injury specifically
includes the loss of limb or function. (JCAHO 1996)
Automation failure (Safety Concern) - CORRECT ANSWER -Examples: equipment
should be fail safe, or alarms should signal; work around plans should be available to recover
from failures. (ESRD) --We should be able to react and respond to automation failures without
compromising patients.
Bad outcome - CORRECT ANSWER -Failure to achieve a desired outcome of care.
(Kohn et al.)
Benign errors - CORRECT ANSWER -Events which cause no harm or lack an adverse
outcome. Also referred to as precursor events or near misses. (Zipperer et al.)
Birth defects, miscarriage, stillbirth or birth with disease (Serious Adverse Reaction) -
CORRECT ANSWER -If exposure to a medical product before conception or during
pregnancy is suspected of causing an adverse outcome in the child. Examples: malformation in
the child caused by the acne drug Accutane, or isotretinoin. (Henkel FDA)
,Blunt end - CORRECT ANSWER -...where regulatory, administrative, and organizational
factors reside.... The blunt end of the system is the source of the resources and constraint that
form the environment where practitioners work. The blunt end is also the source of demands for
production that sharp end practitioners must meet. (Zipperer et al.)
Classification system - CORRECT ANSWER -The categorizing of errors into
distinguishing levels based on their behavior, accountability, outcome, context, or process.
(ESRD)
Cognitive science - CORRECT ANSWER -An amalgamation of disciplines including
artificial intelligence, neuroscience, philosophy, and psychology. Within cognitive science,
cognitive psychology is an umbrella discipline for those interested in cognitive activities such as
perception, learning, memory, language, concept formation, problem solving, and thinking.
(Zipperer et al.)
Communication behaviors that increase risk to patients in operating theatres - CORRECT
ANSWER -Failure to inform team of patient's problem (e.g., surgeon fails to inform
anesthetist of use of drug before blood pressure is seriously affected) and failure to discuss
alternative procedures. (Helmreich)
Communication breakdown related to treatment plan (Safety Concern) - CORRECT
ANSWER -Discrepancies in communication of treatment plan between caregiver and
patient, or between two caregivers. (ESRD)
Communications error - CORRECT ANSWER -(from aviation) Missing or wrong
information exchange or misinterpretation (e.g. misunderstood altitude clearance). (Helmreich)
Constraint and forcing strategies not available (Safety Concern) - CORRECT ANSWER -
There were no checkpoints or required steps that would force individuals to recognize the
pending mistake. Some activities can be engineered so that it is impossible to make a mistake
(e.g., it is impossible to attach an oxygen connector to the suction outlet because the connector is
designed to fit only the O2 outlet). (ESRD)
, Complication - CORRECT ANSWER -A detrimental patient condition that arises during
the process of providing health care, regardless of the setting in which the care is provided. For
instance, perforation, hemorrhage, bacteremia, and adverse reactions to medication (particularly
in the elderly) are four complications of colonoscopy and its associated anesthesia and sedation.
A complication may prolong an inpatient's length of stay or lead to other undesirable outcomes.
(JCAHO 2001)
Critical incident - CORRECT ANSWER -A human error or equipment failure that could
have lead (if not discovered or corrected in time) or did lead to an undesirable outcome, ranging
from increased length of hospital stay to death. (Zipperer et al.)
Critical incident technique - CORRECT ANSWER -A set of procedures for collecting
direct observations of human behavior in such a sway as to facilitate their potential usefulness in
solving practical problems and developing broad psychological principles. (Zipperer et al.)
Death (Serious Adverse Reaction) - CORRECT ANSWER -If an adverse reaction to a
medical product is a suspected cause of a patient's death. (Henkel FDA)
Decision error - CORRECT ANSWER -(from aviation) decision that unnecessarily
increases risk (e.g. unnecessary navigation through adverse weather). (Helmreich)
Disability (Serious Adverse Reaction) - CORRECT ANSWER -If the adverse reaction
caused a significant or permanent change in a patient's body function, physical activities, or
quality of life. Examples: strokes or nervous system disorders brought on by drug therapy.
(FDA)
Dose omission - CORRECT ANSWER -The failure to administer an ordered dose to a
patient before the next scheduled dose, if any. This excludes patients who refuse to take a
medication or a decision not to administer. (NCCMERP)
Environmental stressors (Safety Concern) - CORRECT ANSWER -Workload, workspace,
staffing, time pressures, noise, heat. (ESRD)
