CPPS IHI COMPREHENSIVE EXAM SHEET 2025/2026
QUESTIONS AND ANSWERS GRADED A+
✔✔You have been asked to present an overview of safety events to your hospital's
board of trustees. In order to best represent safety issues, you should:
A. Lead an open discussion of board members' safety concerns and recommendations.
B. Display a graph of the numbers and types of safety events reported in the past year.
C. Present cases of harm with contributing root causes and actions taken.
D. Highlight system-wide improvements that have been implemented in the past year. -
✔✔C. Present cases of harm with contributing root causes and actions taken.
The board of trustees maintains ultimate responsibility for the quality and safety of care
provided. It is important that the board be aware of the harm that occurs within the
facility, the systemic issues that may have caused or contributed to that harm, and the
actions taken to prevent or mitigate the risk of harm.
✔✔A patient safety professional wants to enhance a culture of reporting by introducing
a visual tool that quickly provides the opportunity for frontline staff to share defects,
promote their risk awareness, and share in resolution of defects. The most suitable tool
is:
A. Learning boards
B. Patient safety leadership WalkRounds
C. Root cause analysis
D. Failure modes and effects analysis - ✔✔A. Learning boards
A learning board is a visual tool that enhances frontline staff participation in the
resolution of defects. The other options to do meet the criteria mentioned: Failure
modes and effects analysis is a proactive tool for risk assessment. Root cause analysis
happens after reporting. Patient safety leadership WalkRounds are not a visual tool.
✔✔Your health system learns about an incident involving a retained sponge following
surgery, and an RCA will be performed. The root cause analysis is credible if:
A. It is reviewed and signed by a patient safety professional.
B. Corrective actions have been developed and completed.
C. A single, clearly defined root cause has been identified.
D. There is participation by leadership and individuals closely involved in the process. -
✔✔D. There is participation by leadership and individuals closely involved in the
process.
The Joint Commission Comprehensive Accreditation Manual for Hospitals states that
RCAs for sentinel events, such as this, will be considered acceptable if they are
thorough and credible with "credible" defined as: 1) including participation by leadership
and individuals most closely involved in the process and 2) internally consistent (i.e., the
RCA does not contradict itself).
,✔✔A team is reviewing a serious harm event through the root cause analysis process.
Before it draws any conclusions about the accountability of the provider(s) involved,
what elements should the team consider?
A. How many years the individual has been practicing
B. Whether the individual filed a claim with risk management
C. The individual's most recent performance review
D. The contribution of systems factors on the individual's behavior - ✔✔D. The
contribution of systems factors on the individual's behavior.
The contribution of systems factors on the individual's behavior reflects just culture
principles and the proper approach to use before drawing conclusions about
accountability.
✔✔A hospital's patient safety team is exploring strategies to reduce the number of
patient identification errors in the lab specimen collection process. Which of the
following strategies will provide the highest impact in reduction of errors?
A. Revise the process to allow only one specimen label on the nurse/phlebotomist tray
at a time.
B. Educate all nurses and phlebotomists to ask about patient identifiers before obtaining
specimen.
C. Utilize barcode scanners to generate a specimen label at the bedside.
D. Standardize the process to require the nurse/phlebotomist to ask the patient to state
their name prior to the specimen collection. - ✔✔C. Utilize barcode scanners to
generate a specimen label at the bedside.
Utilizing bar code scanners is the correct answer because it entails a forcing function at
the bedside. After scanning the armband, the correct label for that patient will print from
the scanner.
In regard to the other options: Education is always the lowest impact (soft fix) in any
action plan. Changing processes is better but will still rely on individuals to do the right
thing, e.g., the nurse/phlebotomist would need to make sure multiple labels were not on
the tray, which is a common shortcut to avoid having to walk back and forth between
specimen collections. Direct observation would be required to make sure people didn't
introduce workarounds.
✔✔In the context of failure modes and effects analysis (FMEA), how is the risk priority
number (RPN) used?
A. It prioritizes the failure modes that do not require action.
B. It specifies the failure modes that have been shown to cause harm.
C. It identifies the highest priority failure modes to address.
D. It calculates the failure modes that will create the most errors - ✔✔C. It identifies the
highest priority failure modes to address.
The Risk Priority Number (RPN) is a score that provides the team a way to identify the
highest risk failure modes in descending order. If the team does not have the resources
, to address all the identified risks, this number can be used to filter out failure modes that
are acceptable in the current state.In regard to the other answer options: The RPN does
not determine that an action is not required; that determination comes from the team
evaluating the issue at hand, and, to some degree, may be decided based on time and
resources available. The RPN does not identify error potential or represent harm that
has already occurred; it identifies the impact of a failure mode if it does occur.
✔✔Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS) is a process improvement program that can be used to:
A. Reduce waste.
B. Find the root cause of an incident.
C. Help address disruptive behavior.
D. Eliminate variation. - ✔✔C. Help address disruptive behavior.
TeamSTEPPS can be used to increase communication skills with teams and reduce the
risk of miscommunication that can lead to disruptive behavior.
In regard to the other answer options: Finding the root cause of an incident is
performing a root cause analysis. Reducing waste is Lean process improvement, and
eliminating variation is Six Sigma.
✔✔Your organization utilizes a "home grown" electronic safety event reporting system
that is no longer meeting the needs of the organization. Hospital administration is asking
for your opinion: What would you do for next steps to identify a replacement system?
A. Ask Information Systems to either fix the old system or build a new one.
B. Purchase the least expensive software.
C. Identify key stakeholders and perform a gap analysis of current state to ideal state.
D. Poll colleagues and purchase what they use. - ✔✔C. Identify key stakeholders and
perform a gap analysis of current state to ideal state.
Performing a thorough search of available products that meet the standards for the
organization is the primary action you should take. Once the collated information is
obtained, convening a meeting with the key stakeholders (nursing, medicine, finance,
patient safety, legal, etc.) to determine the organizational needs in relation to the
intended financial impact and return on investment may be required.
✔✔Your hospital is considering implementing a robotic surgery program. As a patient
safety professional, you are concerned about the potential for patient injury associated
with this new technology. The most appropriate tool or technique for assessing potential
risks associated with implementation of the new technology is:
A. Root cause analysis (RCA)
B. Patient safety leadership WalkRounds
C. Failure modes and effects analysis (FMEA)
D. Meaningful use evaluation - ✔✔C. Failure Modes and Effects Analysis (FMEA)The
best answer is FMEA.
QUESTIONS AND ANSWERS GRADED A+
✔✔You have been asked to present an overview of safety events to your hospital's
board of trustees. In order to best represent safety issues, you should:
A. Lead an open discussion of board members' safety concerns and recommendations.
B. Display a graph of the numbers and types of safety events reported in the past year.
C. Present cases of harm with contributing root causes and actions taken.
D. Highlight system-wide improvements that have been implemented in the past year. -
✔✔C. Present cases of harm with contributing root causes and actions taken.
The board of trustees maintains ultimate responsibility for the quality and safety of care
provided. It is important that the board be aware of the harm that occurs within the
facility, the systemic issues that may have caused or contributed to that harm, and the
actions taken to prevent or mitigate the risk of harm.
✔✔A patient safety professional wants to enhance a culture of reporting by introducing
a visual tool that quickly provides the opportunity for frontline staff to share defects,
promote their risk awareness, and share in resolution of defects. The most suitable tool
is:
A. Learning boards
B. Patient safety leadership WalkRounds
C. Root cause analysis
D. Failure modes and effects analysis - ✔✔A. Learning boards
A learning board is a visual tool that enhances frontline staff participation in the
resolution of defects. The other options to do meet the criteria mentioned: Failure
modes and effects analysis is a proactive tool for risk assessment. Root cause analysis
happens after reporting. Patient safety leadership WalkRounds are not a visual tool.
✔✔Your health system learns about an incident involving a retained sponge following
surgery, and an RCA will be performed. The root cause analysis is credible if:
A. It is reviewed and signed by a patient safety professional.
B. Corrective actions have been developed and completed.
C. A single, clearly defined root cause has been identified.
D. There is participation by leadership and individuals closely involved in the process. -
✔✔D. There is participation by leadership and individuals closely involved in the
process.
The Joint Commission Comprehensive Accreditation Manual for Hospitals states that
RCAs for sentinel events, such as this, will be considered acceptable if they are
thorough and credible with "credible" defined as: 1) including participation by leadership
and individuals most closely involved in the process and 2) internally consistent (i.e., the
RCA does not contradict itself).
,✔✔A team is reviewing a serious harm event through the root cause analysis process.
Before it draws any conclusions about the accountability of the provider(s) involved,
what elements should the team consider?
A. How many years the individual has been practicing
B. Whether the individual filed a claim with risk management
C. The individual's most recent performance review
D. The contribution of systems factors on the individual's behavior - ✔✔D. The
contribution of systems factors on the individual's behavior.
The contribution of systems factors on the individual's behavior reflects just culture
principles and the proper approach to use before drawing conclusions about
accountability.
✔✔A hospital's patient safety team is exploring strategies to reduce the number of
patient identification errors in the lab specimen collection process. Which of the
following strategies will provide the highest impact in reduction of errors?
A. Revise the process to allow only one specimen label on the nurse/phlebotomist tray
at a time.
B. Educate all nurses and phlebotomists to ask about patient identifiers before obtaining
specimen.
C. Utilize barcode scanners to generate a specimen label at the bedside.
D. Standardize the process to require the nurse/phlebotomist to ask the patient to state
their name prior to the specimen collection. - ✔✔C. Utilize barcode scanners to
generate a specimen label at the bedside.
Utilizing bar code scanners is the correct answer because it entails a forcing function at
the bedside. After scanning the armband, the correct label for that patient will print from
the scanner.
In regard to the other options: Education is always the lowest impact (soft fix) in any
action plan. Changing processes is better but will still rely on individuals to do the right
thing, e.g., the nurse/phlebotomist would need to make sure multiple labels were not on
the tray, which is a common shortcut to avoid having to walk back and forth between
specimen collections. Direct observation would be required to make sure people didn't
introduce workarounds.
✔✔In the context of failure modes and effects analysis (FMEA), how is the risk priority
number (RPN) used?
A. It prioritizes the failure modes that do not require action.
B. It specifies the failure modes that have been shown to cause harm.
C. It identifies the highest priority failure modes to address.
D. It calculates the failure modes that will create the most errors - ✔✔C. It identifies the
highest priority failure modes to address.
The Risk Priority Number (RPN) is a score that provides the team a way to identify the
highest risk failure modes in descending order. If the team does not have the resources
, to address all the identified risks, this number can be used to filter out failure modes that
are acceptable in the current state.In regard to the other answer options: The RPN does
not determine that an action is not required; that determination comes from the team
evaluating the issue at hand, and, to some degree, may be decided based on time and
resources available. The RPN does not identify error potential or represent harm that
has already occurred; it identifies the impact of a failure mode if it does occur.
✔✔Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS) is a process improvement program that can be used to:
A. Reduce waste.
B. Find the root cause of an incident.
C. Help address disruptive behavior.
D. Eliminate variation. - ✔✔C. Help address disruptive behavior.
TeamSTEPPS can be used to increase communication skills with teams and reduce the
risk of miscommunication that can lead to disruptive behavior.
In regard to the other answer options: Finding the root cause of an incident is
performing a root cause analysis. Reducing waste is Lean process improvement, and
eliminating variation is Six Sigma.
✔✔Your organization utilizes a "home grown" electronic safety event reporting system
that is no longer meeting the needs of the organization. Hospital administration is asking
for your opinion: What would you do for next steps to identify a replacement system?
A. Ask Information Systems to either fix the old system or build a new one.
B. Purchase the least expensive software.
C. Identify key stakeholders and perform a gap analysis of current state to ideal state.
D. Poll colleagues and purchase what they use. - ✔✔C. Identify key stakeholders and
perform a gap analysis of current state to ideal state.
Performing a thorough search of available products that meet the standards for the
organization is the primary action you should take. Once the collated information is
obtained, convening a meeting with the key stakeholders (nursing, medicine, finance,
patient safety, legal, etc.) to determine the organizational needs in relation to the
intended financial impact and return on investment may be required.
✔✔Your hospital is considering implementing a robotic surgery program. As a patient
safety professional, you are concerned about the potential for patient injury associated
with this new technology. The most appropriate tool or technique for assessing potential
risks associated with implementation of the new technology is:
A. Root cause analysis (RCA)
B. Patient safety leadership WalkRounds
C. Failure modes and effects analysis (FMEA)
D. Meaningful use evaluation - ✔✔C. Failure Modes and Effects Analysis (FMEA)The
best answer is FMEA.
