CPPS REVIEW STUDY SHEET 2026 UPDATED
QUESTIONS AND SOLUTIONS
◉ SLIP.
Answer: Action Error
A slip occurs when a person performs the wrong action.
The plan was correct. The intention was correct. The action
performed was wrong.
Characteristics:
Often skill-based tasks
Usually due to distraction
Observable mistake
Examples:
Grabbing the wrong medication vial from a shelf
Clicking the wrong patient in the EHR
Pushing the wrong button on an infusion pump
Think: "I meant to do X, but I accidentally did Y."
◉ LAPSE =.
Answer: Memory Error
,A lapse occurs when a person forgets to perform an intended action.
The plan was correct. The intention was correct. But something was
forgotten.
Characteristics:
Memory failure
Often due to interruptions
Not always visible
Examples:
Forgetting to remove a tourniquet
Forgetting to restart an anticoagulant after a procedure
Omitting a medication dose
Think: "I meant to do it, but it slipped my mind."
◉ If the question describes doing the wrong thing →.
Answer: slip
◉ If the question describes forgetting something →.
Answer: lapse
◉ Mistakes =.
Answer: thinking errors
,◉ Violations.
Answer: deliberate deviations from rules.
Routine violations (normalizing shortcuts)
Situational violations (due to pressure)
Exceptional violations (rare, extreme)
Example: Skipping patient ID check because "I know this patient."
In Just Culture:
Slips/lapses → console & redesign system
At-risk behaviors → coach
Reckless violations → discipline
◉ If the exam scenario describes a distraction leading to a wrong
action →.
Answer: the best response is usually system redesign, not retraining.
◉ At-Risk Behavior →.
Answer: Taking shortcuts, drifting from safe practice
Response: Coach, remove incentives for risky behavior
◉ Reckless Behavior →.
Answer: Conscious disregard of substantial risk
Response: Disciplinary action
, ◉ 3. High Reliability Organizations (HROs).
Answer: Five core principles:
Preoccupation with failure
Reluctance to simplify
Sensitivity to operations
Commitment to resilience
Deference to expertise
If a frontline nurse stops a procedure due to concern and leadership
supports it → that's deference to expertise.
◉ Safety Culture Measurement.
Answer: Tools measure:
Staff perception of teamwork
Leadership support
Reporting comfort
Improvement comes from:
Transparent communication
Feedback loops
Visible leadership engagement
◉ Barcode medication scanning =.
QUESTIONS AND SOLUTIONS
◉ SLIP.
Answer: Action Error
A slip occurs when a person performs the wrong action.
The plan was correct. The intention was correct. The action
performed was wrong.
Characteristics:
Often skill-based tasks
Usually due to distraction
Observable mistake
Examples:
Grabbing the wrong medication vial from a shelf
Clicking the wrong patient in the EHR
Pushing the wrong button on an infusion pump
Think: "I meant to do X, but I accidentally did Y."
◉ LAPSE =.
Answer: Memory Error
,A lapse occurs when a person forgets to perform an intended action.
The plan was correct. The intention was correct. But something was
forgotten.
Characteristics:
Memory failure
Often due to interruptions
Not always visible
Examples:
Forgetting to remove a tourniquet
Forgetting to restart an anticoagulant after a procedure
Omitting a medication dose
Think: "I meant to do it, but it slipped my mind."
◉ If the question describes doing the wrong thing →.
Answer: slip
◉ If the question describes forgetting something →.
Answer: lapse
◉ Mistakes =.
Answer: thinking errors
,◉ Violations.
Answer: deliberate deviations from rules.
Routine violations (normalizing shortcuts)
Situational violations (due to pressure)
Exceptional violations (rare, extreme)
Example: Skipping patient ID check because "I know this patient."
In Just Culture:
Slips/lapses → console & redesign system
At-risk behaviors → coach
Reckless violations → discipline
◉ If the exam scenario describes a distraction leading to a wrong
action →.
Answer: the best response is usually system redesign, not retraining.
◉ At-Risk Behavior →.
Answer: Taking shortcuts, drifting from safe practice
Response: Coach, remove incentives for risky behavior
◉ Reckless Behavior →.
Answer: Conscious disregard of substantial risk
Response: Disciplinary action
, ◉ 3. High Reliability Organizations (HROs).
Answer: Five core principles:
Preoccupation with failure
Reluctance to simplify
Sensitivity to operations
Commitment to resilience
Deference to expertise
If a frontline nurse stops a procedure due to concern and leadership
supports it → that's deference to expertise.
◉ Safety Culture Measurement.
Answer: Tools measure:
Staff perception of teamwork
Leadership support
Reporting comfort
Improvement comes from:
Transparent communication
Feedback loops
Visible leadership engagement
◉ Barcode medication scanning =.
