CPPS IHI FINAL PAPER 2025/2026 QUESTIONS AND
ANSWERS GRADED A+
✔✔When evaluating the conduct of a healthcare worker in the aftermath of a harm
event, which of the following considerations demonstrate consistency with the principles
of a fair and just culture?
A. the severity of the injury that occurred
B. alignment with state health department regulations
C. the impact to the organization's reputation
D. the practice of similarly qualified individuals - ✔✔D. the practice of similarly qualified
individuals
✔✔A patient safety professional receives an event report stating that a physician
ordered anticoagulation medication to be discontinued through the physician order entry
system. The pharmacy computer system did not receive the order, and the patient
received four extra doses of the medication before the order was identified to be
discontinued. The patient safety professional's investigation should focus on
A. software interfaces.
B. decision support.
C. patient identification.
D. business intelligence. - ✔✔A. software interfaces.
✔✔Which of the following concepts describes a situation where violations of safe
practices become regarded as acceptable and are generally tolerated by the group?
A. standards of practice
B. inattentional blindness
C. normalized deviance
D. situational bias - ✔✔C. normalized deviance
✔✔Which of the following types of errors is due to a previous management decision that
impacted design, resulting in patient harm?
A. active error
B. commission error
C. latent error
D. omission error - ✔✔C. latent error
✔✔An incident report relates that a nurse who completed a 12-hour shift on a newly
opened ward forgot to document a skin assessment in the patient's medical record. This
is an example of
A. human error.
B. careless action.
C. at-risk behavior.
D. recklessness. - ✔✔A. human error.
,✔✔Which of the following actions provides evidence that a healthcare organization
considers patients' experiences to improve the safety of patientcare?
A. Consumers, payors, and administrators are represented on committees.
B. Patients receive experience surveys after reviewing charges.
C. Patient feedback is used to redesign care processes.
D. Patient involvement is publicly recognized. - ✔✔C. Patient feedback is used to
redesign care processes.
✔✔A new long-term care facility is being planned. Recognizing that resident injuries
related to falls are a significant concern, a team has been convened to plan, implement,
and evaluate potential solutions. Which of the following interventions will have the
largest impact on the rate of injuries related to falls?
A. Position grab bars in bathrooms.
B. Attach egress alarms to residents.
C. Locate floor pads next to beds.
D. Install impact-absorbing flooring. - ✔✔D. Install impact-absorbing flooring.
✔✔The patient safety professional disseminated a patient safety culture survey to all
employees at a 100-bed hospital. The total response rate was 32%. Which of the
following should the patient safety professional do next?
A. Re-survey the staff to obtain a higher response rate.
B. Form a task force to address the questions on the safety survey.
C. Interpret the results with caution due to the response rate.
D. Contact the managers of the units to identify non-responders. - ✔✔C. Interpret the
results with caution due to the response rate.
✔✔On studying the results of a root cause analysis, it is recognized that an RN missed
steps in a protocol. The RN is regarded as highly competent by colleagues and unit
leaders. The patient safety professional should determine the RN's behavior in this error
to be considered
A. workaround.
B. reckless.
C. high risk.
D. drift. - ✔✔D. drift.
✔✔Patient safety is considered a subset of quality, but it is more difficult to measure in
part because
A. identification of incidents often depends on self-reporting.
B. caregivers are not held accountable to report incidents.
C. incident reporting systems are always anonymous.
D. of dependence on trigger tools to identify safety events. - ✔✔A. identification of
incidents often depends on self-reporting.
✔✔Leadership addressed an unrecognized latent threat in an existing workflow that
was brought to their attention by frontline workers. This is an example of:
,A. preoccupation with failure.
B. decentralized decision making.
C. sensitivity to operations.
D. commitment to resilience. - ✔✔C. sensitivity to operations.
✔✔Leadership has been promoting fair and just culture concepts including non-punitive
response to reporting and the value of near miss reporting. The plan is not universally
supported, and some argue it is a waste of the facility's resources. To support this
leadership initiative, a patient safety professional should explain that the plan is
intended to result in
A. a decrease in event reporting volume due to fewer actual adverse events.
B. a decrease in event reporting due to fewer near misses.
C. an increase in event reporting that will decrease malpractice insurance premiums.
D. an increase in event reporting that will help the hospital identify areas of risk. - ✔✔D.
an increase in event reporting that will help the hospital identify areas of risk.
✔✔Which of the following is the most appropriate method to determine if a root cause
analysis (RCA) should be conducted on an adverse event?
A. Consider only the outcome severity.
B. Consider only blameworthy events.
C. Utilize a risk-based prioritization system.
D. Assess only the probability of recurrence. - ✔✔C. Utilize a risk-based prioritization
system.
✔✔Which of the following strategies is best for facilitating the acceptance of changer
elated to specific performance improvement initiatives?
A. Provide a quarterly statistical report.
B. Utilize storytelling tools.
C. Recognize leadership participation.
D. Distribute weekly newsletters via e-mail. - ✔✔B. Utilize storytelling tools.
✔✔A patient who is a heroin addict and frequent visitor to the emergency department
presented to the hospital with abdominal pain, nausea, and vomiting. He was admitted
for dehydration and potential opioid withdrawal. The patient's abdominal pain worsened
at night, prompting the nurse to call the physician on call. The physician assumed that
the patient was drug-seeking, and increased the patient's methadone. Early the next
morning, the patient experienced severe abdominal pain, showed signs of sepsis, and
was found to have an abdominal perforation. Which cognitive process best describes
the on-call physician's response?
A. hindsight bias
B. implicit bias
C. normalization of the deviant
D. recall bias - ✔✔B. implicit bias
, ✔✔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
What is the Percent Positive Score that should be reported for this item? - ✔✔Correct
Answer: 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%.
✔✔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.
In a culture of safety, staff members are free to report patient safety events, including
close calls or near misses. Managers should have a non-punitive response to staff
involved in errors and reward staff who report safety issues. Even though the error did
not reach the patient or cause harm, it needs further investigation to identify any system
failures, and to ensure that a process is in place to prevent an error from reaching the
patient and causing harm.
✔✔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.
ANSWERS GRADED A+
✔✔When evaluating the conduct of a healthcare worker in the aftermath of a harm
event, which of the following considerations demonstrate consistency with the principles
of a fair and just culture?
A. the severity of the injury that occurred
B. alignment with state health department regulations
C. the impact to the organization's reputation
D. the practice of similarly qualified individuals - ✔✔D. the practice of similarly qualified
individuals
✔✔A patient safety professional receives an event report stating that a physician
ordered anticoagulation medication to be discontinued through the physician order entry
system. The pharmacy computer system did not receive the order, and the patient
received four extra doses of the medication before the order was identified to be
discontinued. The patient safety professional's investigation should focus on
A. software interfaces.
B. decision support.
C. patient identification.
D. business intelligence. - ✔✔A. software interfaces.
✔✔Which of the following concepts describes a situation where violations of safe
practices become regarded as acceptable and are generally tolerated by the group?
A. standards of practice
B. inattentional blindness
C. normalized deviance
D. situational bias - ✔✔C. normalized deviance
✔✔Which of the following types of errors is due to a previous management decision that
impacted design, resulting in patient harm?
A. active error
B. commission error
C. latent error
D. omission error - ✔✔C. latent error
✔✔An incident report relates that a nurse who completed a 12-hour shift on a newly
opened ward forgot to document a skin assessment in the patient's medical record. This
is an example of
A. human error.
B. careless action.
C. at-risk behavior.
D. recklessness. - ✔✔A. human error.
,✔✔Which of the following actions provides evidence that a healthcare organization
considers patients' experiences to improve the safety of patientcare?
A. Consumers, payors, and administrators are represented on committees.
B. Patients receive experience surveys after reviewing charges.
C. Patient feedback is used to redesign care processes.
D. Patient involvement is publicly recognized. - ✔✔C. Patient feedback is used to
redesign care processes.
✔✔A new long-term care facility is being planned. Recognizing that resident injuries
related to falls are a significant concern, a team has been convened to plan, implement,
and evaluate potential solutions. Which of the following interventions will have the
largest impact on the rate of injuries related to falls?
A. Position grab bars in bathrooms.
B. Attach egress alarms to residents.
C. Locate floor pads next to beds.
D. Install impact-absorbing flooring. - ✔✔D. Install impact-absorbing flooring.
✔✔The patient safety professional disseminated a patient safety culture survey to all
employees at a 100-bed hospital. The total response rate was 32%. Which of the
following should the patient safety professional do next?
A. Re-survey the staff to obtain a higher response rate.
B. Form a task force to address the questions on the safety survey.
C. Interpret the results with caution due to the response rate.
D. Contact the managers of the units to identify non-responders. - ✔✔C. Interpret the
results with caution due to the response rate.
✔✔On studying the results of a root cause analysis, it is recognized that an RN missed
steps in a protocol. The RN is regarded as highly competent by colleagues and unit
leaders. The patient safety professional should determine the RN's behavior in this error
to be considered
A. workaround.
B. reckless.
C. high risk.
D. drift. - ✔✔D. drift.
✔✔Patient safety is considered a subset of quality, but it is more difficult to measure in
part because
A. identification of incidents often depends on self-reporting.
B. caregivers are not held accountable to report incidents.
C. incident reporting systems are always anonymous.
D. of dependence on trigger tools to identify safety events. - ✔✔A. identification of
incidents often depends on self-reporting.
✔✔Leadership addressed an unrecognized latent threat in an existing workflow that
was brought to their attention by frontline workers. This is an example of:
,A. preoccupation with failure.
B. decentralized decision making.
C. sensitivity to operations.
D. commitment to resilience. - ✔✔C. sensitivity to operations.
✔✔Leadership has been promoting fair and just culture concepts including non-punitive
response to reporting and the value of near miss reporting. The plan is not universally
supported, and some argue it is a waste of the facility's resources. To support this
leadership initiative, a patient safety professional should explain that the plan is
intended to result in
A. a decrease in event reporting volume due to fewer actual adverse events.
B. a decrease in event reporting due to fewer near misses.
C. an increase in event reporting that will decrease malpractice insurance premiums.
D. an increase in event reporting that will help the hospital identify areas of risk. - ✔✔D.
an increase in event reporting that will help the hospital identify areas of risk.
✔✔Which of the following is the most appropriate method to determine if a root cause
analysis (RCA) should be conducted on an adverse event?
A. Consider only the outcome severity.
B. Consider only blameworthy events.
C. Utilize a risk-based prioritization system.
D. Assess only the probability of recurrence. - ✔✔C. Utilize a risk-based prioritization
system.
✔✔Which of the following strategies is best for facilitating the acceptance of changer
elated to specific performance improvement initiatives?
A. Provide a quarterly statistical report.
B. Utilize storytelling tools.
C. Recognize leadership participation.
D. Distribute weekly newsletters via e-mail. - ✔✔B. Utilize storytelling tools.
✔✔A patient who is a heroin addict and frequent visitor to the emergency department
presented to the hospital with abdominal pain, nausea, and vomiting. He was admitted
for dehydration and potential opioid withdrawal. The patient's abdominal pain worsened
at night, prompting the nurse to call the physician on call. The physician assumed that
the patient was drug-seeking, and increased the patient's methadone. Early the next
morning, the patient experienced severe abdominal pain, showed signs of sepsis, and
was found to have an abdominal perforation. Which cognitive process best describes
the on-call physician's response?
A. hindsight bias
B. implicit bias
C. normalization of the deviant
D. recall bias - ✔✔B. implicit bias
, ✔✔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
What is the Percent Positive Score that should be reported for this item? - ✔✔Correct
Answer: 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%.
✔✔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.
In a culture of safety, staff members are free to report patient safety events, including
close calls or near misses. Managers should have a non-punitive response to staff
involved in errors and reward staff who report safety issues. Even though the error did
not reach the patient or cause harm, it needs further investigation to identify any system
failures, and to ensure that a process is in place to prevent an error from reaching the
patient and causing harm.
✔✔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.
