CPPS Review Course
Questions and Answers — All Correct
Edition
Comprehensive Certification Examination
150 Multiple-Choice Questions Aligned with the IBHPS / IHI-NPSF Certified
Professional in Patient Safety (CPPS) Exam Blueprint
Total Questions: 150 | Sections: 8 | Format: Single best answer (A–D)
Cognitive Distribution: 25% Recall | 50% Application | 25% Analysis
Question Style: 75% Scenario-Based | 25% Direct Knowledge
Aligned with the CPPS Exam Blueprint Domains:
1. Patient Safety Fundamentals & Culture (Q1–Q20)
2. Human Factors & Systems Thinking (Q21–Q40)
3. Risk Identification & Assessment (Q41–Q60)
4. Patient Safety Interventions & Error Prevention (Q61–Q80)
5. Measurement, Analysis, & Improvement (Q81–Q100)
6. Communication, Teamwork, & Leadership (Q101–Q115)
7. Patient Engagement & Advocacy (Q116–Q130)
8. Regulatory, Accreditation, & Legal Issues (Q131–Q150)
Each question includes a stem, four options (A–D) with the single correct answer marked *[CORRECT]*, the
correct-answer letter, and a 2–4 sentence rationale citing the CPPS exam blueprint and current patient safety
standards.
,CPPS Review Course — Q&A All Correct — 2026/2027 Edition IBHPS / IHI-NPSF Aligned
Section 1: Patient Safety Fundamentals & Culture
Q1–Q20 cover the foundational concepts of patient safety, safety culture, just culture, psychological safety, HROs,
HSOPSC/SAQ, sentinel events, never events, disclosure, and second victim phenomenon.
Q1: A 68-year-old hospitalized patient receives a tenfold overdose of insulin due to a misread order.
The patient suffers hypoglycemic coma but survives after intensive intervention. According to the
IOM taxonomy, this event is BEST classified as:
A. A near miss because the patient survived
B. An adverse event resulting from a medical error and preventable harm *[CORRECT]*
C. A sentinel event because insulin is a high-alert medication
D. An expected complication of inpatient diabetes management
Correct Answer: B
Rationale: An adverse event is harm caused by medical management rather than the disease process; when the overdose resulted
from a misread order it is both a medical error and preventable harm, satisfying the IOM definitions in the CPPS Fundamentals
domain. Near misses cause no harm (A), sentinel events are unexpected occurrences involving death or severe harm requiring
investigation (C), and a tenfold overdose is never an expected complication (D).
Q2: Which foundational report FIRST quantified preventable medical harm in U.S. hospitals at
44,000–98,000 deaths annually and catalyzed the modern patient safety movement?
A. Crossing the Quality Chasm (2001)
B. To Err Is Human: Building a Safer Health System (1999) *[CORRECT]*
C. The NHS Plan (2000)
D. An Organization with a Memory (2000)
Correct Answer: B
Rationale: To Err Is Human (IOM, 1999) provided the landmark 44,000–98,000 deaths estimate and is the foundational document
tested under the CPPS Fundamentals/Patient Safety Movement competency. Crossing the Quality Chasm (2001) (A) defined the six
aims of quality but did not originate the mortality estimate. The NHS Plan (C) and An Organization with a Memory (D) are U.K.
documents that followed the IOM report.
Q3: A hospital's leadership team reviews the results of their annual HSOPSC survey. Scores are
high for 'teamwork within units' (75%) but low for 'nonpunitive response to error' (35%) and
'frequency of events reported' (40%). The MOST accurate interpretation is that the organization has:
A. A mature reporting culture but weak teamwork
B. Strong teamwork climate but a weak reporting and just culture *[CORRECT]*
C. A high-reliability organization profile
D. A blame-free culture that over-rewards reporting
Correct Answer: B
Rationale: The HSOPSC distinguishes teamwork climate from nonpunitive response and reporting frequency; high teamwork with
low nonpunitive response and low reporting frequency indicates strong unit teamwork but a weak just and reporting culture per the
CPPS safety-culture competency. Option A reverses the findings, (C) is unsupported because HROs require strong scores across
all dimensions, and (D) misreads low nonpunitive scores as 'blame-free.'
Page 2
,CPPS Review Course — Q&A All Correct — 2026/2027 Edition IBHPS / IHI-NPSF Aligned
Q4: A nurse manager discovers a medication near miss and chooses not to file an incident report
because 'no harm reached the patient and the physician would be upset.' Which behavior does this
PRIMARILY reflect, and what is its system-level consequence?
A. A just-culture violation leading to improved peer relationships
B. A reporting-culture failure that deprives the organization of learning opportunities and weakens
proactive risk detection *[CORRECT]*
C. An appropriate application of nonpunitive response
D. A violation of HIPAA privacy rules
Correct Answer: B
Rationale: Near-miss reporting is a cornerstone of a learning culture and is essential for proactive risk identification under the
CPPS blueprint; suppressing near misses eliminates the organizational signal needed to prevent future harm. Option A mislabels
underreporting as a just-culture principle, (C) conflates nonpunitive response with not reporting, and (D) is unrelated to privacy
law.
Q5: After a serious medication error, the involved nurse becomes tearful, expresses self-doubt ('I'm
a terrible nurse'), and considers leaving the profession. This response is BEST described as:
A. Burnout from chronic workload stress
B. The second victim phenomenon requiring supportive intervention *[CORRECT]*
C. Moral injury from systemic ethical conflict
D. A punitive response by the organization
Correct Answer: B
Rationale: The second victim phenomenon describes clinicians who experience emotional distress after adverse events; supportive
interventions (e.g., peer support, RISE, Scott's three-tier model) are tested under the CPPS Fundamentals/Culture domain. Burnout
(A) reflects chronic stress rather than an acute event, moral injury (C) describes transgression of moral beliefs, and (D)
misattributes an internal response to organizational action.
Q6: Which of the following combinations BEST describes the five dimensions of safety culture
measured by the HSOPSC?
A. Teamwork, communication, leadership, staffing, burnout
B. Teamwork within units, supervisor expectations, organizational learning, management support,
nonpunitive response to error *[CORRECT]*
C. Safety climate, teamwork climate, job satisfaction, perceptions of management, working conditions
D. Just culture, reporting culture, learning culture, flexible culture, informed culture
Correct Answer: B
Rationale: The HSOPSC's 12 composites include teamwork within units, supervisor expectations/actions promoting safety,
organizational learning, management support, and nonpunitive response to error — the CPPS-tested safety culture assessment
tool. Option C lists SAQ dimensions (a different tool), and Option D lists Reason's five cultures of safety (conceptual, not
HSOPSC).
Page 3
, CPPS Review Course — Q&A All Correct — 2026/2027 Edition IBHPS / IHI-NPSF Aligned
Q7: An ICU multidisciplinary team implements daily safety huddles, brief pre-procedure time-outs,
and structured debriefs after critical events. Leadership rounds weekly to reinforce safety priorities.
These practices are MOST characteristic of which type of organization?
A. A blame-culture organization emphasizing individual accountability
B. A high-reliability organization demonstrating preoccupation with failure and sensitivity to
operations *[CORRECT]*
C. A compliance-driven organization focused on regulatory minimums
D. A volume-driven organization focused on throughput metrics
Correct Answer: B
Rationale: Weick and Sutcliffe's HRO principles include preoccupation with failure, sensitivity to operations, commitment to
resilience, deference to expertise, and reluctance to simplify — operationalized through huddles, briefs, debriefs, and leadership
rounding per the CPPS Fundamentals/HRO competency. The other options describe cultural pathologies inconsistent with HRO
behavior.
Q8: A patient dies after a wrong-site surgery. Under The Joint Commission sentinel event policy, the
hospital is REQUIRED to:
A. Pay financial compensation to the family within 30 days
B. Conduct a root cause analysis and submit a sentinel event report with corrective actions
*[CORRECT]*
C. Terminate the surgeon involved within 60 days
D. Publicly post the event on the hospital website within 7 days
Correct Answer: B
Rationale: TJC's sentinel event policy requires facilities to perform an RCA, develop corrective action plans, and submit the report
(voluntarily or in response to review) per the CPPS Regulatory domain. Compensation (A) is a legal matter outside TJC scope,
termination (C) misapplies just-culture principles, and public posting (D) is not a TJC requirement.
Q9: Which principle distinguishes a 'just culture' from both a 'blame culture' and a 'blame-free
culture'?
A. All errors are punished equally regardless of intent
B. Human errors are managed consolingly, at-risk behaviors are coached, and reckless behaviors
are disciplined *[CORRECT]*
C. All errors are excused to encourage maximum reporting
D. Errors are reported only when no policy violation occurred
Correct Answer: B
Rationale: Marx's just-culture algorithm distinguishes human error (console), at-risk behavior (coach), and reckless behavior
(discipline) — the CPPS-tested distinction that avoids both blame and blame-free extremes. Option A describes a blame culture,
(C) describes a blame-free culture, and (D) undermines reporting culture by conditioning it on policy compliance.
Page 4
Questions and Answers — All Correct
Edition
Comprehensive Certification Examination
150 Multiple-Choice Questions Aligned with the IBHPS / IHI-NPSF Certified
Professional in Patient Safety (CPPS) Exam Blueprint
Total Questions: 150 | Sections: 8 | Format: Single best answer (A–D)
Cognitive Distribution: 25% Recall | 50% Application | 25% Analysis
Question Style: 75% Scenario-Based | 25% Direct Knowledge
Aligned with the CPPS Exam Blueprint Domains:
1. Patient Safety Fundamentals & Culture (Q1–Q20)
2. Human Factors & Systems Thinking (Q21–Q40)
3. Risk Identification & Assessment (Q41–Q60)
4. Patient Safety Interventions & Error Prevention (Q61–Q80)
5. Measurement, Analysis, & Improvement (Q81–Q100)
6. Communication, Teamwork, & Leadership (Q101–Q115)
7. Patient Engagement & Advocacy (Q116–Q130)
8. Regulatory, Accreditation, & Legal Issues (Q131–Q150)
Each question includes a stem, four options (A–D) with the single correct answer marked *[CORRECT]*, the
correct-answer letter, and a 2–4 sentence rationale citing the CPPS exam blueprint and current patient safety
standards.
,CPPS Review Course — Q&A All Correct — 2026/2027 Edition IBHPS / IHI-NPSF Aligned
Section 1: Patient Safety Fundamentals & Culture
Q1–Q20 cover the foundational concepts of patient safety, safety culture, just culture, psychological safety, HROs,
HSOPSC/SAQ, sentinel events, never events, disclosure, and second victim phenomenon.
Q1: A 68-year-old hospitalized patient receives a tenfold overdose of insulin due to a misread order.
The patient suffers hypoglycemic coma but survives after intensive intervention. According to the
IOM taxonomy, this event is BEST classified as:
A. A near miss because the patient survived
B. An adverse event resulting from a medical error and preventable harm *[CORRECT]*
C. A sentinel event because insulin is a high-alert medication
D. An expected complication of inpatient diabetes management
Correct Answer: B
Rationale: An adverse event is harm caused by medical management rather than the disease process; when the overdose resulted
from a misread order it is both a medical error and preventable harm, satisfying the IOM definitions in the CPPS Fundamentals
domain. Near misses cause no harm (A), sentinel events are unexpected occurrences involving death or severe harm requiring
investigation (C), and a tenfold overdose is never an expected complication (D).
Q2: Which foundational report FIRST quantified preventable medical harm in U.S. hospitals at
44,000–98,000 deaths annually and catalyzed the modern patient safety movement?
A. Crossing the Quality Chasm (2001)
B. To Err Is Human: Building a Safer Health System (1999) *[CORRECT]*
C. The NHS Plan (2000)
D. An Organization with a Memory (2000)
Correct Answer: B
Rationale: To Err Is Human (IOM, 1999) provided the landmark 44,000–98,000 deaths estimate and is the foundational document
tested under the CPPS Fundamentals/Patient Safety Movement competency. Crossing the Quality Chasm (2001) (A) defined the six
aims of quality but did not originate the mortality estimate. The NHS Plan (C) and An Organization with a Memory (D) are U.K.
documents that followed the IOM report.
Q3: A hospital's leadership team reviews the results of their annual HSOPSC survey. Scores are
high for 'teamwork within units' (75%) but low for 'nonpunitive response to error' (35%) and
'frequency of events reported' (40%). The MOST accurate interpretation is that the organization has:
A. A mature reporting culture but weak teamwork
B. Strong teamwork climate but a weak reporting and just culture *[CORRECT]*
C. A high-reliability organization profile
D. A blame-free culture that over-rewards reporting
Correct Answer: B
Rationale: The HSOPSC distinguishes teamwork climate from nonpunitive response and reporting frequency; high teamwork with
low nonpunitive response and low reporting frequency indicates strong unit teamwork but a weak just and reporting culture per the
CPPS safety-culture competency. Option A reverses the findings, (C) is unsupported because HROs require strong scores across
all dimensions, and (D) misreads low nonpunitive scores as 'blame-free.'
Page 2
,CPPS Review Course — Q&A All Correct — 2026/2027 Edition IBHPS / IHI-NPSF Aligned
Q4: A nurse manager discovers a medication near miss and chooses not to file an incident report
because 'no harm reached the patient and the physician would be upset.' Which behavior does this
PRIMARILY reflect, and what is its system-level consequence?
A. A just-culture violation leading to improved peer relationships
B. A reporting-culture failure that deprives the organization of learning opportunities and weakens
proactive risk detection *[CORRECT]*
C. An appropriate application of nonpunitive response
D. A violation of HIPAA privacy rules
Correct Answer: B
Rationale: Near-miss reporting is a cornerstone of a learning culture and is essential for proactive risk identification under the
CPPS blueprint; suppressing near misses eliminates the organizational signal needed to prevent future harm. Option A mislabels
underreporting as a just-culture principle, (C) conflates nonpunitive response with not reporting, and (D) is unrelated to privacy
law.
Q5: After a serious medication error, the involved nurse becomes tearful, expresses self-doubt ('I'm
a terrible nurse'), and considers leaving the profession. This response is BEST described as:
A. Burnout from chronic workload stress
B. The second victim phenomenon requiring supportive intervention *[CORRECT]*
C. Moral injury from systemic ethical conflict
D. A punitive response by the organization
Correct Answer: B
Rationale: The second victim phenomenon describes clinicians who experience emotional distress after adverse events; supportive
interventions (e.g., peer support, RISE, Scott's three-tier model) are tested under the CPPS Fundamentals/Culture domain. Burnout
(A) reflects chronic stress rather than an acute event, moral injury (C) describes transgression of moral beliefs, and (D)
misattributes an internal response to organizational action.
Q6: Which of the following combinations BEST describes the five dimensions of safety culture
measured by the HSOPSC?
A. Teamwork, communication, leadership, staffing, burnout
B. Teamwork within units, supervisor expectations, organizational learning, management support,
nonpunitive response to error *[CORRECT]*
C. Safety climate, teamwork climate, job satisfaction, perceptions of management, working conditions
D. Just culture, reporting culture, learning culture, flexible culture, informed culture
Correct Answer: B
Rationale: The HSOPSC's 12 composites include teamwork within units, supervisor expectations/actions promoting safety,
organizational learning, management support, and nonpunitive response to error — the CPPS-tested safety culture assessment
tool. Option C lists SAQ dimensions (a different tool), and Option D lists Reason's five cultures of safety (conceptual, not
HSOPSC).
Page 3
, CPPS Review Course — Q&A All Correct — 2026/2027 Edition IBHPS / IHI-NPSF Aligned
Q7: An ICU multidisciplinary team implements daily safety huddles, brief pre-procedure time-outs,
and structured debriefs after critical events. Leadership rounds weekly to reinforce safety priorities.
These practices are MOST characteristic of which type of organization?
A. A blame-culture organization emphasizing individual accountability
B. A high-reliability organization demonstrating preoccupation with failure and sensitivity to
operations *[CORRECT]*
C. A compliance-driven organization focused on regulatory minimums
D. A volume-driven organization focused on throughput metrics
Correct Answer: B
Rationale: Weick and Sutcliffe's HRO principles include preoccupation with failure, sensitivity to operations, commitment to
resilience, deference to expertise, and reluctance to simplify — operationalized through huddles, briefs, debriefs, and leadership
rounding per the CPPS Fundamentals/HRO competency. The other options describe cultural pathologies inconsistent with HRO
behavior.
Q8: A patient dies after a wrong-site surgery. Under The Joint Commission sentinel event policy, the
hospital is REQUIRED to:
A. Pay financial compensation to the family within 30 days
B. Conduct a root cause analysis and submit a sentinel event report with corrective actions
*[CORRECT]*
C. Terminate the surgeon involved within 60 days
D. Publicly post the event on the hospital website within 7 days
Correct Answer: B
Rationale: TJC's sentinel event policy requires facilities to perform an RCA, develop corrective action plans, and submit the report
(voluntarily or in response to review) per the CPPS Regulatory domain. Compensation (A) is a legal matter outside TJC scope,
termination (C) misapplies just-culture principles, and public posting (D) is not a TJC requirement.
Q9: Which principle distinguishes a 'just culture' from both a 'blame culture' and a 'blame-free
culture'?
A. All errors are punished equally regardless of intent
B. Human errors are managed consolingly, at-risk behaviors are coached, and reckless behaviors
are disciplined *[CORRECT]*
C. All errors are excused to encourage maximum reporting
D. Errors are reported only when no policy violation occurred
Correct Answer: B
Rationale: Marx's just-culture algorithm distinguishes human error (console), at-risk behavior (coach), and reckless behavior
(discipline) — the CPPS-tested distinction that avoids both blame and blame-free extremes. Option A describes a blame culture,
(C) describes a blame-free culture, and (D) undermines reporting culture by conditioning it on policy compliance.
Page 4
