CPPS IHI PRACTICE EXAM QUESTIONS WITH COMPLETE SOLUTIONS!!
/ACTUAL EXAM QUESTIONS AND ANSWERS PLUS RATIONALES
GRADED A+ ASSURED
Question 1
A recent hospital initiative to decrease venous thromboembolism (VTE) was not successful,
despite implementing a training program for staff. An interprofessional team came together to
analyze the persistent problem. Pharmacists reported that patients often refused anticoagulant
injections, particularly the midnight dose. Nurses reported that patients did not care to be
awakened and given an injection, and, other times, nurses withheld the injection because the
patient was walking to the bathroom.
Which of the following steps is the most important for the team to take to address this
problem?
A) Request that pharmacy and nursing brainstorm solutions with their staff.
B) Share the data with decision makers and continue to monitor run charts.
C) Use the Plan-Do-Study-Act (PDSA) cycle method for improvement.
D) Require staff to attend an annual training on professional guidelines.
Correct Answer: C) Use the Plan-Do-Study-Act (PDSA) cycle method for improvement.
Rationale: The PDSA cycle is a structured, scientific method for testing changes in a real-world
setting. It allows the team to test various ideas for improvement on a small scale (e.g.,
changing the timing of the dose, improving patient education about refusal), study the
results, and then act on what is learned before implementing a change broadly. More training
is unlikely to help if the issue is patient refusal or workflow barriers. Brainstorming is part of
the "Plan" step, but PDSA provides the complete framework for testing and learning.
Question 2
Which of the following is considered to be a scientific method of process improvement for
testing a change in a real work setting?
A) Failure mode and effects analysis (FMEA)
B) Root cause analysis (RCA)
C) Event analysis
D) Plan-Do-Study-Act (PDSA) cycle
,Correct Answer: D) Plan-Do-Study-Act (PDSA) cycle
Rationale: The PDSA cycle is a scientific method of process improvement that involves
planning a change, trying it, observing the results, and acting on what is learned. It serves as a
guide for testing a change in a real work setting. RCA and event analysis are reactive tools
used to understand the causes of an adverse event that has already occurred. FMEA is a
proactive tool used to identify potential failures in a process before it is implemented.
Question 3
An example of a descriptive statistics measure for central tendency is:
A) Standard deviation
B) Range
C) Standard error of the mean
D) Mode
Correct Answer: D) Mode
Rationale: Measures of central tendency describe the center of a data set. The mode (the
most frequent value), the mean (average), and the median (middle value) are all measures of
central tendency. Range, standard deviation, and standard error of the mean are all measures
of variation or spread in the data.
Question 4
A patient safety professional is monitoring incident reports submitted for near misses and minor
events to identify areas of potential patient safety risk. Over the last few months, there has
been a steady decline in the number of reports being submitted each week. There have been
some leadership changes, but the staff has been stable with no major personnel issues.
Which of the following actions should be taken in response to this change?
A) Report the data as a positive trend and celebrate the improved performance.
B) Ensure reporting is being emphasized and feedback on submitted reports is occurring.
C) Continue to monitor for fluctuations; no action is required at this time.
D) Issue a message to the staff that failure to report can lead to discipline.
,Correct Answer: B) Ensure reporting is being emphasized and feedback on submitted reports
is occurring.
Rationale: A decline in reporting is often a sign of a weakening safety culture, not an
improvement in safety. To foster a robust reporting culture, leaders must encourage
reporting, remove barriers, and, crucially, provide feedback to staff so they know their reports
are being reviewed and used for improvement. A punitive approach (discipline) will further
suppress reporting. Ignoring the trend or celebrating it as an improvement are incorrect and
potentially dangerous interpretations.
Question 5
You are a patient safety officer for a community hospital that has had many falls resulting in
serious injuries. A "No Pass Zone" initiative was piloted on one of the units several months ago.
You are scheduled to present the results of the pilot to leadership. Your goal is to get
leadership's buy in to implement the "No Pass Zone" initiative throughout the entire hospital.
What chart would be best to show leadership the impact of the "No Pass Zone" initiative over
time?
A) Run chart
B) Control chart
C) Shewhart chart
D) Pareto chart
Correct Answer: A) Run chart
Rationale: A run chart is a simple yet powerful tool for displaying data over time. It allows you
to plot a measure (e.g., falls per 1,000 patient days) chronologically and annotate when a
change was implemented. This makes it easy for leadership to visually see the impact of the
"No Pass Zone" initiative on the fall rate before and after its implementation. A Pareto chart is
used to prioritize problems, not show change over time.
Question 6
A root cause analysis team has recommended the following action item: "The manager will
provide the care team with training on the proper use of personal protective equipment
, required while caring for a patient with tuberculosis."
Which of the following is a process measure the team might use to track this action?
A) The number of reported staff exposures to tuberculosis
B) Percentage of staff with positive TB skin tests
C) The number of personal protective equipment purchased
D) The percentage of staff observed to be correctly using personal protective equipment
Correct Answer: D) The percentage of staff observed to be correctly using personal protective
equipment
Rationale: A process measure evaluates whether a task or action is being performed as
intended. In this case, the action is training, and the intended process is the correct use of
PPE. Directly observing and measuring the percentage of staff using PPE correctly is a direct
measure of the process. The other options are outcome measures, as they measure the result
or impact of the process.
Question 7
A patient safety officer has been asked to compare the incidence of medication omissions on
two medical surgical units. To normalize the data for a fair comparison, the patient safety officer
should compare the:
A) Medication errors per administered dose on each unit
B) Total number of medication errors on each unit
C) Total number of medication omissions on each unit
D) Medication omissions per administered dose on each unit
Correct Answer: D) Medication omissions per administered dose on each unit
Rationale: To accurately compare events between two units of potentially different sizes or
patient volumes, you must use a rate, not a raw number. Since the specific request is about
"medication omissions," the correct numerator is medication omissions. The denominator
should be a measure of opportunity, such as doses administered. This creates a normalized
rate (omissions per dose) that allows for a meaningful comparison.
/ACTUAL EXAM QUESTIONS AND ANSWERS PLUS RATIONALES
GRADED A+ ASSURED
Question 1
A recent hospital initiative to decrease venous thromboembolism (VTE) was not successful,
despite implementing a training program for staff. An interprofessional team came together to
analyze the persistent problem. Pharmacists reported that patients often refused anticoagulant
injections, particularly the midnight dose. Nurses reported that patients did not care to be
awakened and given an injection, and, other times, nurses withheld the injection because the
patient was walking to the bathroom.
Which of the following steps is the most important for the team to take to address this
problem?
A) Request that pharmacy and nursing brainstorm solutions with their staff.
B) Share the data with decision makers and continue to monitor run charts.
C) Use the Plan-Do-Study-Act (PDSA) cycle method for improvement.
D) Require staff to attend an annual training on professional guidelines.
Correct Answer: C) Use the Plan-Do-Study-Act (PDSA) cycle method for improvement.
Rationale: The PDSA cycle is a structured, scientific method for testing changes in a real-world
setting. It allows the team to test various ideas for improvement on a small scale (e.g.,
changing the timing of the dose, improving patient education about refusal), study the
results, and then act on what is learned before implementing a change broadly. More training
is unlikely to help if the issue is patient refusal or workflow barriers. Brainstorming is part of
the "Plan" step, but PDSA provides the complete framework for testing and learning.
Question 2
Which of the following is considered to be a scientific method of process improvement for
testing a change in a real work setting?
A) Failure mode and effects analysis (FMEA)
B) Root cause analysis (RCA)
C) Event analysis
D) Plan-Do-Study-Act (PDSA) cycle
,Correct Answer: D) Plan-Do-Study-Act (PDSA) cycle
Rationale: The PDSA cycle is a scientific method of process improvement that involves
planning a change, trying it, observing the results, and acting on what is learned. It serves as a
guide for testing a change in a real work setting. RCA and event analysis are reactive tools
used to understand the causes of an adverse event that has already occurred. FMEA is a
proactive tool used to identify potential failures in a process before it is implemented.
Question 3
An example of a descriptive statistics measure for central tendency is:
A) Standard deviation
B) Range
C) Standard error of the mean
D) Mode
Correct Answer: D) Mode
Rationale: Measures of central tendency describe the center of a data set. The mode (the
most frequent value), the mean (average), and the median (middle value) are all measures of
central tendency. Range, standard deviation, and standard error of the mean are all measures
of variation or spread in the data.
Question 4
A patient safety professional is monitoring incident reports submitted for near misses and minor
events to identify areas of potential patient safety risk. Over the last few months, there has
been a steady decline in the number of reports being submitted each week. There have been
some leadership changes, but the staff has been stable with no major personnel issues.
Which of the following actions should be taken in response to this change?
A) Report the data as a positive trend and celebrate the improved performance.
B) Ensure reporting is being emphasized and feedback on submitted reports is occurring.
C) Continue to monitor for fluctuations; no action is required at this time.
D) Issue a message to the staff that failure to report can lead to discipline.
,Correct Answer: B) Ensure reporting is being emphasized and feedback on submitted reports
is occurring.
Rationale: A decline in reporting is often a sign of a weakening safety culture, not an
improvement in safety. To foster a robust reporting culture, leaders must encourage
reporting, remove barriers, and, crucially, provide feedback to staff so they know their reports
are being reviewed and used for improvement. A punitive approach (discipline) will further
suppress reporting. Ignoring the trend or celebrating it as an improvement are incorrect and
potentially dangerous interpretations.
Question 5
You are a patient safety officer for a community hospital that has had many falls resulting in
serious injuries. A "No Pass Zone" initiative was piloted on one of the units several months ago.
You are scheduled to present the results of the pilot to leadership. Your goal is to get
leadership's buy in to implement the "No Pass Zone" initiative throughout the entire hospital.
What chart would be best to show leadership the impact of the "No Pass Zone" initiative over
time?
A) Run chart
B) Control chart
C) Shewhart chart
D) Pareto chart
Correct Answer: A) Run chart
Rationale: A run chart is a simple yet powerful tool for displaying data over time. It allows you
to plot a measure (e.g., falls per 1,000 patient days) chronologically and annotate when a
change was implemented. This makes it easy for leadership to visually see the impact of the
"No Pass Zone" initiative on the fall rate before and after its implementation. A Pareto chart is
used to prioritize problems, not show change over time.
Question 6
A root cause analysis team has recommended the following action item: "The manager will
provide the care team with training on the proper use of personal protective equipment
, required while caring for a patient with tuberculosis."
Which of the following is a process measure the team might use to track this action?
A) The number of reported staff exposures to tuberculosis
B) Percentage of staff with positive TB skin tests
C) The number of personal protective equipment purchased
D) The percentage of staff observed to be correctly using personal protective equipment
Correct Answer: D) The percentage of staff observed to be correctly using personal protective
equipment
Rationale: A process measure evaluates whether a task or action is being performed as
intended. In this case, the action is training, and the intended process is the correct use of
PPE. Directly observing and measuring the percentage of staff using PPE correctly is a direct
measure of the process. The other options are outcome measures, as they measure the result
or impact of the process.
Question 7
A patient safety officer has been asked to compare the incidence of medication omissions on
two medical surgical units. To normalize the data for a fair comparison, the patient safety officer
should compare the:
A) Medication errors per administered dose on each unit
B) Total number of medication errors on each unit
C) Total number of medication omissions on each unit
D) Medication omissions per administered dose on each unit
Correct Answer: D) Medication omissions per administered dose on each unit
Rationale: To accurately compare events between two units of potentially different sizes or
patient volumes, you must use a rate, not a raw number. Since the specific request is about
"medication omissions," the correct numerator is medication omissions. The denominator
should be a measure of opportunity, such as doses administered. This creates a normalized
rate (omissions per dose) that allows for a meaningful comparison.
