CPPS IHI UPDATED PRACTICE SOLUTION
QUESTIONS AND VERIFIED ANSWERS
●● Nearing the end of her 18-hour work shift, a resident sees a patient
with extremely high blood glucose levels. She writes the patient a
prescription for insulin; however, in her exhaustion, she closes her "U"
(for "units"), and it looks more like an extra zero. As a result, the
pharmacist dispenses an insulin dose that's ten times stronger than the
patient needs.
To prevent this problem from happening again, which of the following
would be the best course of action?
(A) Punish the resident and the pharmacist for their careless actions.
(B) Require both the resident and the pharmacist to take additional
training.
(C) Develop a system that prevents messy handwriting from causing
miscommunication that leads to error.
(D) Ensure that no prescribing physician is ever tired or distracted.
Answer: (C) Develop a system that prevents messy handwriting from
causing miscommunication that leads to error.
●● "Latent errors" are best defined as:
(A) Defects in the design and organization of processes and systems.
(B) Errors in patient care that don't ever result in harm and thus go
undetected.
, (C) Mistakes in patient care that providers fail to report due to fear of
punishment.
(D) Errors in patient care that cause immediate adverse effects.
Answer: Defects in the design and organization of processes and
systems.
●● Two women — one named Camilla Tyler, the other named Camilla
Taylor — arrive at a particularly busy emergency department at about
the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an
antibiotic. The doctor orders the medications, but mixes up the patients
when filling out the order sheets. The pharmacist dispenses the
medications as ordered, and the nurse administers an antibiotic to Ms.
Tyler and a sedative to Ms. Taylor.
What is the active error in this scenario?
(A) The forms are completed by hand at the same time for different
patients.
(B) The nurse administers an antibiotic to Ms. Tyler and a sedative to
Ms. Taylor.
(C) The emergency department is particularly busy.
(D) The pharmacist doesn't notice that the order sheets are incorrectly
filled out
Answer: (B) The nurse administers an antibiotic to Ms. Tyler and a
sedative to Ms. Taylor.
●● Two women — one named Camilla Tyler, the other named Camilla
Taylor — arrive at a particularly busy emergency department at about
QUESTIONS AND VERIFIED ANSWERS
●● Nearing the end of her 18-hour work shift, a resident sees a patient
with extremely high blood glucose levels. She writes the patient a
prescription for insulin; however, in her exhaustion, she closes her "U"
(for "units"), and it looks more like an extra zero. As a result, the
pharmacist dispenses an insulin dose that's ten times stronger than the
patient needs.
To prevent this problem from happening again, which of the following
would be the best course of action?
(A) Punish the resident and the pharmacist for their careless actions.
(B) Require both the resident and the pharmacist to take additional
training.
(C) Develop a system that prevents messy handwriting from causing
miscommunication that leads to error.
(D) Ensure that no prescribing physician is ever tired or distracted.
Answer: (C) Develop a system that prevents messy handwriting from
causing miscommunication that leads to error.
●● "Latent errors" are best defined as:
(A) Defects in the design and organization of processes and systems.
(B) Errors in patient care that don't ever result in harm and thus go
undetected.
, (C) Mistakes in patient care that providers fail to report due to fear of
punishment.
(D) Errors in patient care that cause immediate adverse effects.
Answer: Defects in the design and organization of processes and
systems.
●● Two women — one named Camilla Tyler, the other named Camilla
Taylor — arrive at a particularly busy emergency department at about
the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an
antibiotic. The doctor orders the medications, but mixes up the patients
when filling out the order sheets. The pharmacist dispenses the
medications as ordered, and the nurse administers an antibiotic to Ms.
Tyler and a sedative to Ms. Taylor.
What is the active error in this scenario?
(A) The forms are completed by hand at the same time for different
patients.
(B) The nurse administers an antibiotic to Ms. Tyler and a sedative to
Ms. Taylor.
(C) The emergency department is particularly busy.
(D) The pharmacist doesn't notice that the order sheets are incorrectly
filled out
Answer: (B) The nurse administers an antibiotic to Ms. Tyler and a
sedative to Ms. Taylor.
●● Two women — one named Camilla Tyler, the other named Camilla
Taylor — arrive at a particularly busy emergency department at about
