CPPS IHI CORE EXAMS MANUAL 2025/2026 QUESTIONS
AND ANSWERS GRADED A+
✔✔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.) A single, clearly defined root cause has been identified.
B.) It is reviewed and signed by a patient safety professional.
C.) There is participation by leadership and individuals closely involved in the process.
D.) Corrective actions have been developed and completed. - ✔✔C.) 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.) The contribution of systems factors on the individual's behavior
B.) How many years the individual has been practicing
C.) The individual's most recent performance review
D.) Whether the individual filed a claim with risk management - ✔✔A.) The contribution
of system 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.) Educate all nurses and phlebotomists to ask about patient identifiers before
obtaining specimen.
B.) Revise the process to allow only one specimen label on the nurse/phlebotomist tray
at a time.
C.) Standardize the process to require the nurse/phlebotomist to ask the patient to state
their name prior to the specimen collection.
D.) Utilize barcode scanners to generate a specimen label at the bedside. - ✔✔D.)
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 calculates the failure modes that will create the most errors.
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 prioritizes the failure modes that do not require action. - ✔✔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.) Eliminate variation.
B.) Help address disruptive behavior.
C.) Find the root cause of an incident.
D.) Reduce waste. - ✔✔B.) 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.) Purchase the least expensive software.
B.) Ask Information Systems to either fix the old system or build a new one.
C.) Poll colleagues and purchase what they use.
, D.) Identify key stakeholders and perform a gap analysis of current state to ideal state. -
✔✔D.) 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.) Meaningful use evaluation
B.) Failure modes and effects analysis (FMEA)
C.) Patient safety leadership WalkRounds
D.) Root cause analysis (RCA) - ✔✔B.) Failure Modes and Effects Analysis (FMEA)The
best answer is FMEA.
FMEA is a prospective risk reduction strategy; ideally, it is used before a new
technology is implemented to determine how the new technology might fail and cause
harm. Patient safety leadership WalkRounds are designed to help leaders gather facts
about the care environment and create positive relationships between staff and
administration. Root cause analysis is a retrospective tool; it is used after a harmful
event or near miss to determine what went wrong. Meaningful use evaluation is for
evaluating the success of implementing an electronic health record.
✔✔Why is it important to share lessons learned from RCAs?
A.) It exposes the fallibility of the clinician(s) involved.
B.) It allows others to introduce workarounds to avoid the same situation.
C.) It allows co-workers to learn the rationale for why an event occurred and incorporate
new lessons learned into practice
D.) Sharing these events should not be encouraged because it increases the risk of
litigation. - ✔✔C.) It allows co-workers to learn the rationale for why an event occurred
and incorporate new lessons learned into practice.
Sharing allows others to adopt new methods and to heighten risk awareness. In regard
to the other possible answers: The goal of an RCA is not to place blame on individual
clinicians, and workarounds are oftentimes unsafe practices that ignore systems issues
that require fixing. Sharing lessons learned from an RCA may decrease the risk of
litigation by improving patient safety and reducing the likelihood of an adverse event
occurring again.
AND ANSWERS GRADED A+
✔✔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.) A single, clearly defined root cause has been identified.
B.) It is reviewed and signed by a patient safety professional.
C.) There is participation by leadership and individuals closely involved in the process.
D.) Corrective actions have been developed and completed. - ✔✔C.) 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.) The contribution of systems factors on the individual's behavior
B.) How many years the individual has been practicing
C.) The individual's most recent performance review
D.) Whether the individual filed a claim with risk management - ✔✔A.) The contribution
of system 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.) Educate all nurses and phlebotomists to ask about patient identifiers before
obtaining specimen.
B.) Revise the process to allow only one specimen label on the nurse/phlebotomist tray
at a time.
C.) Standardize the process to require the nurse/phlebotomist to ask the patient to state
their name prior to the specimen collection.
D.) Utilize barcode scanners to generate a specimen label at the bedside. - ✔✔D.)
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 calculates the failure modes that will create the most errors.
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 prioritizes the failure modes that do not require action. - ✔✔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.) Eliminate variation.
B.) Help address disruptive behavior.
C.) Find the root cause of an incident.
D.) Reduce waste. - ✔✔B.) 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.) Purchase the least expensive software.
B.) Ask Information Systems to either fix the old system or build a new one.
C.) Poll colleagues and purchase what they use.
, D.) Identify key stakeholders and perform a gap analysis of current state to ideal state. -
✔✔D.) 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.) Meaningful use evaluation
B.) Failure modes and effects analysis (FMEA)
C.) Patient safety leadership WalkRounds
D.) Root cause analysis (RCA) - ✔✔B.) Failure Modes and Effects Analysis (FMEA)The
best answer is FMEA.
FMEA is a prospective risk reduction strategy; ideally, it is used before a new
technology is implemented to determine how the new technology might fail and cause
harm. Patient safety leadership WalkRounds are designed to help leaders gather facts
about the care environment and create positive relationships between staff and
administration. Root cause analysis is a retrospective tool; it is used after a harmful
event or near miss to determine what went wrong. Meaningful use evaluation is for
evaluating the success of implementing an electronic health record.
✔✔Why is it important to share lessons learned from RCAs?
A.) It exposes the fallibility of the clinician(s) involved.
B.) It allows others to introduce workarounds to avoid the same situation.
C.) It allows co-workers to learn the rationale for why an event occurred and incorporate
new lessons learned into practice
D.) Sharing these events should not be encouraged because it increases the risk of
litigation. - ✔✔C.) It allows co-workers to learn the rationale for why an event occurred
and incorporate new lessons learned into practice.
Sharing allows others to adopt new methods and to heighten risk awareness. In regard
to the other possible answers: The goal of an RCA is not to place blame on individual
clinicians, and workarounds are oftentimes unsafe practices that ignore systems issues
that require fixing. Sharing lessons learned from an RCA may decrease the risk of
litigation by improving patient safety and reducing the likelihood of an adverse event
occurring again.
