CPPS IHI EXAM EVALUAATION 2025/2026 QUESTIONS
AND ANSWERS GRADED A+
✔✔1. The Just Culture model includes creating a learning culture, designing safe
systems, and which of the following activities?
A. Finding the individual to blame
B. Managing behavioral choices
C. Providing punishment equal to the harm caused
D. Decreasing the amount of reported errors - ✔✔B. Managing behavioral choices
A Just Culture is a learning culture in which people learn from mistakes and/or potential
mistakes. In a Just Culture, people look at all the factors that led to a harm event (or
factors that may lead to harm), including behavioral choices, so that future harm can be
prevented.
Finding the individual to blame is incorrect because in a Just Culture, the focus is on
system failures. Providing punishment equal to the severity of harm is incorrect because
in a Just Culture, punishment is related to intent to do harm. Decreasing the amount of
reported errors is incorrect because in a Just Culture, you would actually expect an
increase of reported errors, especially related to near misses and/or great catches.
✔✔A nurse on a medical-surgical unit does not comply with the barcode medication
administration (BCMA) procedure while caring for one of her patients. Her supervisor is
deciding how to respond. As her supervisor, what would you do?
A. Request that the pharmacy run a report of the BCMA compliance rates of the unit.
B. Ask staff if there are adequate scanners to meet their needs.
C. Ask the nurse what was occurring at the time, and why she chose to bypass the
policy.
D. Counsel the nurse on the importance of following policy. - ✔✔C. Ask the nurse what
was occurring at the time and why she chose to bypass the policy.
In determining the appropriate response to a violation of policy, it is important to learn
what the incentive was for the behavior and what conditions led the staff member to
their action. The Just Culture algorithm can serve as a guide.
In this case, it is important to understand the nurse's rationale for diverting from the
policy. For example, did she think the benefit outweighed the risk for some reason?
✔✔Which of the following is the best first step in changing the culture of safety in a
health care organization?
A. Develop policies, procedures, and checklists for safety.
B. Hire an experienced patient safety officer with a strong performance record.
C. Conduct an assessment and gather focused data.
D. Implement communication and teamwork tools. - ✔✔C. Conduct an assessment and
gather focused data.
,As a first step in improving the culture, an assessment and data review are necessary to
determine the current strengths and weaknesses of the organization. Once strengths
and weaknesses are identified, then focused action plans can be developed for
improvement. (New policies and procedures and/or communication and teamwork tools
could be part of the action plans). Having a patient safety officer is important but not as
central to the improvement effort as the data.
✔✔As your organization's patient safety officer, you are reviewing unit results on the
AHRQ Culture of Safety Survey. You are speaking with the manager of a unit for which
the unit percent positive score is 30 percent for the following statement: "Staff in this unit
work longer hours than is best for patient care." What do you tell the manager the
positive answer in this statement means?
A. 0% of the staff agree with the statement.
B. 30% of the staff work longer hours.
C. 30% of the staff disagree with the statement.
D. 70% of the staff work longer hours. - ✔✔C. 30% of the staff disagree with the
statement.
The percent positive score refers to answers that reflect the presence of patient safety.
In this case, the question is asking about a risk to patient safety, so the responses of
"agree" and "strongly agree" are negative responses for patient safety. The percent
positive score of 30% means that 30% of the staff disagreed with this statement,
thereby saying that patient safety is present.
✔✔When setting organizational safety priorities, it is best to:
A. Determine priorities based on pay-for-performance measurements.
B. Develop a mechanism to gather input from a variety of sources.
C. Review the current literature to identify areas of frequent concern.
D. Focus primarily on accreditation standards and requirements. - ✔✔B. Develop a
mechanism to gather input from a variety of sources.
In order to understand the variety of safety issues that an organization faces, it is best to
solicit concerns from a variety of sources. Focusing primarily on performance
measurements or accreditation requirements will not identify or address the full range of
possible priorities. Having information from a variety of sources will ensure all areas of
importance are captured.
✔✔A hospital is attempting to engage the board in their quality endeavors. Which is the
best strategy to improve the board's involvement?
A. Align the quality measures with the hospital's strategic goals.
B. Set only goals that can be attained.
C. Focus only on measures that are tied to reimbursement.
D. Report all quality measures to the board. - ✔✔A. Align the quality measures with the
hospital's strategic goals.
, If quality/safety measures are aligned with the hospital's strategic goals, this assures
that everyone across the system, from the board to the frontline staff, have quality and
safety as a point of focus. Reporting all quality measures to the board is too broad and
not practical; measures across the system should be rolled into fewer overarching
strategic measures that the board can reasonably review.Focusing only on measures
that are tied to reimbursement might be a barrier to aligning your quality measures with
strategic initiatives, and it could lead to neglect of important areas for improvement.
(Notably, the list of outcome measures that the Centers for Medicare & Medicaid
Services ties to reimbursement consistently grows; if you focus only on measures
currently tied to reimbursement, you could fall behind.)Setting only goals that can be
attained is incorrect because it would encourage average performance rather than
continuous improvement and excellence.
✔✔Which of the following is required to begin the journey to a culture of safety?
A. RCA teams must look at errors as individual failures.
B. Care should be provider-centered rather than patient-centered.
C. Care should depend on independent, individual performance excellence.
D. Accountability must be universal and reciprocal, not just top-down. - ✔✔D.
Accountability must be universal and reciprocal, not just top-down.
A just culture maintains standards of universal and reciprocal accountability. A just
culture also favors patient-centered (as opposed to provider-centered) care; encourages
interdependency, collaboration, and inter-professional teamwork; and believes that the
causes of most errors can be traced to system failures.
✔✔You are meeting with your organization's CFO to review the likely Return on
Investment (ROI) for several possible patient safety initiatives. Based only on the
projected ROI, which project is most likely to receive the CFO's approval?
A. Implementation of Computerized Provider Order Entry to reduce the number of
medication errors with an ROI of 1.0, or 100 percent.
B. Procurement of new beds with built-in alarms to reduce falls with an ROI of 0.9, or 90
percent.
C. Implementation of evidence-based guidelines to reduce the rate of catheter-
associated urinary tract infections with an ROI of 3.0, or 300 percent.
D. Implementation of a sitter program, which has been shown to reduce falls and
improve patient satisfaction with an ROI of 0.5, or 50 percent. - ✔✔C. Implementation of
evidence-based guidelines to reduce the rate of catheter-associated urinary tract
infections with an ROI of 3.0, or 300 percent.
With an anticipated ROI greater than 100 percent, reducing catheter-associated urinary
tract infections is most likely to receive the CFO's approval based on the ROI alone.
✔✔Which of the following tactics is the best approach to increase near-miss event
reporting?
A. Include staff names in event reports.
B. Give staff up to a week to report events.
AND ANSWERS GRADED A+
✔✔1. The Just Culture model includes creating a learning culture, designing safe
systems, and which of the following activities?
A. Finding the individual to blame
B. Managing behavioral choices
C. Providing punishment equal to the harm caused
D. Decreasing the amount of reported errors - ✔✔B. Managing behavioral choices
A Just Culture is a learning culture in which people learn from mistakes and/or potential
mistakes. In a Just Culture, people look at all the factors that led to a harm event (or
factors that may lead to harm), including behavioral choices, so that future harm can be
prevented.
Finding the individual to blame is incorrect because in a Just Culture, the focus is on
system failures. Providing punishment equal to the severity of harm is incorrect because
in a Just Culture, punishment is related to intent to do harm. Decreasing the amount of
reported errors is incorrect because in a Just Culture, you would actually expect an
increase of reported errors, especially related to near misses and/or great catches.
✔✔A nurse on a medical-surgical unit does not comply with the barcode medication
administration (BCMA) procedure while caring for one of her patients. Her supervisor is
deciding how to respond. As her supervisor, what would you do?
A. Request that the pharmacy run a report of the BCMA compliance rates of the unit.
B. Ask staff if there are adequate scanners to meet their needs.
C. Ask the nurse what was occurring at the time, and why she chose to bypass the
policy.
D. Counsel the nurse on the importance of following policy. - ✔✔C. Ask the nurse what
was occurring at the time and why she chose to bypass the policy.
In determining the appropriate response to a violation of policy, it is important to learn
what the incentive was for the behavior and what conditions led the staff member to
their action. The Just Culture algorithm can serve as a guide.
In this case, it is important to understand the nurse's rationale for diverting from the
policy. For example, did she think the benefit outweighed the risk for some reason?
✔✔Which of the following is the best first step in changing the culture of safety in a
health care organization?
A. Develop policies, procedures, and checklists for safety.
B. Hire an experienced patient safety officer with a strong performance record.
C. Conduct an assessment and gather focused data.
D. Implement communication and teamwork tools. - ✔✔C. Conduct an assessment and
gather focused data.
,As a first step in improving the culture, an assessment and data review are necessary to
determine the current strengths and weaknesses of the organization. Once strengths
and weaknesses are identified, then focused action plans can be developed for
improvement. (New policies and procedures and/or communication and teamwork tools
could be part of the action plans). Having a patient safety officer is important but not as
central to the improvement effort as the data.
✔✔As your organization's patient safety officer, you are reviewing unit results on the
AHRQ Culture of Safety Survey. You are speaking with the manager of a unit for which
the unit percent positive score is 30 percent for the following statement: "Staff in this unit
work longer hours than is best for patient care." What do you tell the manager the
positive answer in this statement means?
A. 0% of the staff agree with the statement.
B. 30% of the staff work longer hours.
C. 30% of the staff disagree with the statement.
D. 70% of the staff work longer hours. - ✔✔C. 30% of the staff disagree with the
statement.
The percent positive score refers to answers that reflect the presence of patient safety.
In this case, the question is asking about a risk to patient safety, so the responses of
"agree" and "strongly agree" are negative responses for patient safety. The percent
positive score of 30% means that 30% of the staff disagreed with this statement,
thereby saying that patient safety is present.
✔✔When setting organizational safety priorities, it is best to:
A. Determine priorities based on pay-for-performance measurements.
B. Develop a mechanism to gather input from a variety of sources.
C. Review the current literature to identify areas of frequent concern.
D. Focus primarily on accreditation standards and requirements. - ✔✔B. Develop a
mechanism to gather input from a variety of sources.
In order to understand the variety of safety issues that an organization faces, it is best to
solicit concerns from a variety of sources. Focusing primarily on performance
measurements or accreditation requirements will not identify or address the full range of
possible priorities. Having information from a variety of sources will ensure all areas of
importance are captured.
✔✔A hospital is attempting to engage the board in their quality endeavors. Which is the
best strategy to improve the board's involvement?
A. Align the quality measures with the hospital's strategic goals.
B. Set only goals that can be attained.
C. Focus only on measures that are tied to reimbursement.
D. Report all quality measures to the board. - ✔✔A. Align the quality measures with the
hospital's strategic goals.
, If quality/safety measures are aligned with the hospital's strategic goals, this assures
that everyone across the system, from the board to the frontline staff, have quality and
safety as a point of focus. Reporting all quality measures to the board is too broad and
not practical; measures across the system should be rolled into fewer overarching
strategic measures that the board can reasonably review.Focusing only on measures
that are tied to reimbursement might be a barrier to aligning your quality measures with
strategic initiatives, and it could lead to neglect of important areas for improvement.
(Notably, the list of outcome measures that the Centers for Medicare & Medicaid
Services ties to reimbursement consistently grows; if you focus only on measures
currently tied to reimbursement, you could fall behind.)Setting only goals that can be
attained is incorrect because it would encourage average performance rather than
continuous improvement and excellence.
✔✔Which of the following is required to begin the journey to a culture of safety?
A. RCA teams must look at errors as individual failures.
B. Care should be provider-centered rather than patient-centered.
C. Care should depend on independent, individual performance excellence.
D. Accountability must be universal and reciprocal, not just top-down. - ✔✔D.
Accountability must be universal and reciprocal, not just top-down.
A just culture maintains standards of universal and reciprocal accountability. A just
culture also favors patient-centered (as opposed to provider-centered) care; encourages
interdependency, collaboration, and inter-professional teamwork; and believes that the
causes of most errors can be traced to system failures.
✔✔You are meeting with your organization's CFO to review the likely Return on
Investment (ROI) for several possible patient safety initiatives. Based only on the
projected ROI, which project is most likely to receive the CFO's approval?
A. Implementation of Computerized Provider Order Entry to reduce the number of
medication errors with an ROI of 1.0, or 100 percent.
B. Procurement of new beds with built-in alarms to reduce falls with an ROI of 0.9, or 90
percent.
C. Implementation of evidence-based guidelines to reduce the rate of catheter-
associated urinary tract infections with an ROI of 3.0, or 300 percent.
D. Implementation of a sitter program, which has been shown to reduce falls and
improve patient satisfaction with an ROI of 0.5, or 50 percent. - ✔✔C. Implementation of
evidence-based guidelines to reduce the rate of catheter-associated urinary tract
infections with an ROI of 3.0, or 300 percent.
With an anticipated ROI greater than 100 percent, reducing catheter-associated urinary
tract infections is most likely to receive the CFO's approval based on the ROI alone.
✔✔Which of the following tactics is the best approach to increase near-miss event
reporting?
A. Include staff names in event reports.
B. Give staff up to a week to report events.
