QUESTION

1. Some CPPS questions reported from
different exam takers
1. Ground rounds
2. Blame-free, just culture, accountability culture
3. FMEA: why, how
4. RCA involve front line staff
5. Physician made an error. He wants to apologize and assume responsibility of that error. What can
the physician make to increase the acceptance by the patient?
a. Don’t touch the patient
b. Let him ask questions
c. Say what happened in simple understood language without repetition
d. State facts, no emotions
6. Agency which makes regulations:
a. AHRQ
b. NQF
c. CMS
d. JCI
7. When you report an error to the state:
a. Say all the data you have till the point
b. Seek the help of the JCI
c. Mention who were involved

2. 8. A new monitor is being used for following the patient status. The monitor is new, nurses not
trained on it and the unit was understaffed. The monitor is still not connected to the light alarm at
the door of the patient’s room. What error this unit may face?
a. The nurse may not receive the alert in a timely manner
b. There will be nobody at the nursing station
c. The patient my stop the alarm because of noise
d. The nurse will not be able to turn the alarm off
9. The emergency department show delay in treatment as there is a conflict with the external lab
they are dealing with. The lab states that they are adhering to HIPAA regulations. As a patient
safety professional, you can help in resolving this matter by clarifying:
a. The lab can release the reports with “form of release”
b. No authorization is needed to share data with the treating physician
c. They can share the data after verbal permission from the patient
10. The vendor of new equipment wants to make a focus group with the nursing staff to determine
their needs before establishing the new equipment. As a patient safety professional, what do you
recommend?
a. Nursing directors should be recruited to the focus group because they know about the
policies the staff apply
b. HIPAA authorization should be obtained before the focus group
c. Vendors should proceed as they know
11. A physician had made a fatal error. By analysis they found that all other clinicians will do the same
thing if they were in the same situation. What is your recommendation as a patient safety
professional?
a. Support him, fix the system

3. b. Make training to all the clinicians
c. Take disciplinary action against him
12. An adverse event was found to be due to human error, but not from recklessness. The CPPS must
consider:
a. That every human error has a cause behind
13. Swiss cheese model can be used to explain:
a. Active and latent errors
b. How human errors can affect a complex system
14. The NQF issues report of serious events which is useful to:
a. Encourage reporting of safety events
b. Report adverse events related to specific care
c. Provide information about preventable events
d. Reporting rare events
15. Line Graph about IHI Trigger tool and the difference between a trigger, identified and observed
events and voluntary reports.
Between April and May, the adverse events are:
0
20
40
60
80
100
120
January
February
March
April
May
June
July
August
September
October
November
December
daily census
triggers
observed and
confirmed medical
errors
voluntary reports
identified ADE Trigger

4. a. Tampering
b. Common cause
16. Line Graph about IHI Trigger tool and the difference between a trigger, identified and observed
events and voluntary reports.
Your action based on the above data is:
a. Find a correlation between increased staffing and reduced reporting.
b. Report to the leadership that the overall safety culture is positive
c. Report the survey findings to the JCI
17. Line Graph about IHI Trigger tool and the difference between a trigger, identified and observed
events and voluntary reports.(medication administration errors)
a. It is difficult for the medical staff to calculate the denominator
b. It is difficult for the medical staff to calculate the numerator
c. It is not important to report the medication error, the culture survey is more important
0
20
40
60
80
100
120
January
February
March
April
May
June
July
August
September
October
November
December
daily census
triggers
observed and
confirmed medical
errors
voluntary reports
identified ADE Trigger

5. 18. Double bar graph comparing the results of AHRQ culture survey of the hospital vs AHRQ results.
Your action based on the above data is:
a. Find a correlation between increased staffing and reduced reporting.
b. Report to the leadership that the overall safety culture is positive
c. Report the survey findings to the JCI
0
10
20
30
40
50
60
70
80
90
The organization
AHRQ National Average

6. 19. Double bar graph comparing the results of AHRQ culture survey of the hospital vs AHRQ results.
Your recommendation as a PSP is:
a. Find a consultant for team training
b. Educate the staff about the importance of reporting
20. Which of these actions show closed loop communication?
a. Feedback
21. A nurse has worked double shifts during the weekend. There was a female in labor and two
syringes prepared at bedside. One for the epidural anesthetic and the other for antibiotic. The
nurse mixed the syringe and gave the patient the anesthetic by IV mistakenly. The patient died
and her baby.
The actions of the hospital included:
1- Labeling of medications
2- Color coding of epidural drugs
3- Training for all nursing OR staff
4- The faulty nurse was terminated
0
10
20
30
40
50
60
70
80
90
The organization
AHRQ National Average

7. Which of the following could be the root causes?
a. Labeling of the drugs should be more carefully noticed
b. If she didn’t work at weekends, she wouldn’t have done the error
c. The error occurred because the two drugs were at the same place
22. A nurse has worked double shifts during the weekend. There was a female in labor and two
syringes prepared at bedside. One for the epidural anesthetic and the other for antibiotic. The
nurse mixed the syringe and gave the patient the anesthetic by IV mistakenly. The patient died
and her baby.
The actions of the hospital included:
1- Labeling of medications
2- Color coding of epidural drugs
3- Training for all nursing OR staff
4- The faulty nurse was terminated
The anesthesiologist complained that the nursing staff should prepare the two syringes before
calling him. A report was filled for this issue. There was an order for all nurses to prepare the
drugs in such a case. This is called:
a. Disruptive behavior from nurses
b. They are making at-risk shortcuts to decease delays
c. Negligence from the nurse
23. A nurse has worked double shifts during the weekend. There was a female in labor and two
syringes prepared at bedside. One for the epidural anesthetic and the other for antibiotic. The
nurse mixed the syringe and gave the patient the anesthetic by IV mistakenly. The patient died
and her baby.
The actions of the hospital included:

8. 1. Labeling of medications
2. Color coding of epidural drugs
3. Training for all nursing OR staff
4. The faulty nurse was terminated
As a PSP, you can conclude that:
a. The improvement actions were not system focused
b. Training of nurses will increase the error
c. If the policy is not validated, it will not work
24. There is a policy and it is well known that no one follows it. This is called:
a. Normalized deviance
25. Near misses should not be disclosed
26. The surgical staff is using a surgical checklist before operations. The software shos complete
adherence to that checklist. When the surveyor came, he said that the staff is using the checklist
incorrectly. What is the appropriate action?
a. Train the staff about correct use of the list
b. Make an unannounced observation
c. Check the PS culture
27. The CPPS is acting as a project manager of establishing PS program. The first thing to do is:
a. Define the scope of the program
28. We want to establish a PS committee and the senior leaders refuse. How can the PSP convince the
leaders?
a. Make one of them a member in the committee
b. Help in performing cost analysis and ROI study
29. Which of the following is an evidence of patient engagement during care?

9. a. The patient agrees about the treatment plan decided by the clinician
b. The patient can ask question anytime during his care
30. A patient has received an overdose from an anticoagulant. He expires the day after. The physician
believes that the anticoagulant helped (but was not the main cause) of the patient death. The
physician wants to investigate the active and latent errors that took place. One of the latent
errors could be:
a. The patient had an unidentified allergy from the anticoagulant
b. Infusion pumps usually flaws
c. There is a nursing error
d. Active error by equipment failure
e. Latent error that the nurse didn’t stop the infusion
31. A heparin product single dose was all recalled and all the available heparin is in multi-dose vials.
What is the appropriate action?
a. Work with the pharmacist about dispensing prefilled syringes
b. Make check on the dispensed syringes by two nurses
32. There were many cases that have been underreported in a hospital. The appropriate action is
a. Educate the staff about the importance of reporting
b. Make incentives
c. Check the culture
33. Which of these sources provide minimal hindsight bias for information regarding patient safety?
a. Claims
b. RCA
c. Observations
34. Which of the following sources provide data about patient-centered care?

10. a. Patient and family survey
35. The main advantages of using validated cultural assessment surveys
a. Credibility during comparing data
36. Which of the following can encourage reporting of adverse events
a. Incentive system
b. feedback
c. Explain its importance
37. An organization suffered from a terrible event which was reported in the media. All parties were
affected: the patient family and physician. When the organization starts to work again, they
should
a. Give a vacation for the physician to heal
b. Avoid talking about the issue with the staff
c. Study the system and identify opportunities for improvement
38. A hospital has two hundred beds and many errors have been reported. When it expanded to three
hundred beds, the reports decreased. What is the main reason?
a. The system was not integrated
39. Putting a smiley face on the door of the patient’s room who has high risk to fall even when the
census is high applies to which principle in the HROs:
A. Preoccupation with failure
B. Reluctance to simplify
C. Sensitivity to operations
D. Commitment to resilience
40. Putting smiley faces on the rooms of a surgical ward which are assigned for surgery patients
applies to which principle of HROs:

11. A. Preoccupation with failure
B. Reluctance to simplify
C. Sensitivity to operations
D. Commitment to resilience
41. An organization had a problem in communication. What is the best action?
a. Bring a consultant for CRM training
42. A tool that shows special and common cause variation is called
a. Control chart
b. Run chart
43. A diamond in the flow chart stands for
a. Decision
b. Process step
c. Document
44. Patients in a certain community do not speak English and are considered to have health literacy.
As a patient safety officer what do you recommend?
a. Asses the cultural competency of the organization
b. Identify patients with limited English proficiency
c. Provide English training to the community
45. When success occurs in one department, study it to disseminate to other units
46. After a serious event takes place. Make
a. RCA
b. Cause and effect analysis
c. FMEA
47. Asses severity of the event

12. 48. The best strategy for integrating/implementing patient safety is
a. Align patient safety with strategic goals, mission , and vision
49. An error took place in an organization that is applying state law. What is the best action?
a. Reporting is mandatory to JCI, voluntary to
b. Reporting is voluntary to JCI, mandatory to the state
50. What is the best strategy that the top management can use to encourage the staff to apply
patient safety?
a. Discuss with them an improvement issue and let them recommend actions
b. Make a contest to choose the patient safety slogan
51. Idea: Leadership walkaround for creating a culture of safety
52. A physical therapy unit had a patient who was about to fall. Despite the availability of reporting
errors the last two years show no fall data. How do you justify this?
a. Staff do not know that they have to report near misses
53. You are about to purchase a new software for event reporting. It is predicted that
a. Rate of AE reporting(number of reports ) increases
b. Rate of AE reporting(number of reports ) decreases
c. That there is no change in number of reports
54. There was a critical lab value received and put in the patient card. The physician came and did not
notice that critical value, which was important in diagnosis and drug therapy. What do you
recommend?
a. Make critical value alert in electronic medical reports
b. Ask physicians to read lab results in a timely manner
c. Educate the physicians about the critical lab results

13. 55. A survey showed that sixty percent of the patients did not know about their diagnosis, surgery,
and alternative treatments. They sign the consent and never ask. As a safety officer, what do you
recommend?
a. Make brochures educating the patients about the importance of surgical safety
b. Change the consent format/procedure
56. When the organization engages the patient during the analysis of errors. This is
a. Evidence of transparency
b. The patient may help to uncover errors that we cannot notice
57. Job aids
58. In performing RCA, what is the first question to ask?
a. What happened
b. How did it happen
c. Who did it
d. Why did it happen
59. The first step that the patient safety professional will do to take to check failures in a process is
a. Map it (charting)
60. The patient fall data collected for the last year is:
22 24 17 16 8 7 7 7 6.
As a patient safety professional, what should you do next?
a. Celebrate success
b. Monitor the data using run chart
61. A report to the governing body about the patient safety culture assessment should contain
a. Data for the overall organization (summary)
b. Data for each department

14. 62. As a PSP, how could you show the benefits from LD Walkaround? (What should be included in a
report of walkaround result for assessing patient safety)
a. Number of walks that led to RCA
b. Time of walkaround, shift
63. A physician made a mistake by performing a wrong site biopsy. When making RCA,you have to
consider:
Situational awareness
64. Idea: Many questions discussing identifying barrier to learning and understanding
65. A nurse made an error and they gave her training. As a patient safety professional what should
you consider?
a. Whether the error was a knowledge-based or skill-based and remodify the training
b. Document the training in her file
66. A drug has an alert of recall. As a PSP what should you do?
a. Check if that lot number is in your organization
b. Send a notification to all departments
67. A ventilator has a safety alert. As a PSP what should you do?
a. Inform the respiratory therapist
b. Forward the alert
c. Check the availability of rental ventilator in your facility
68. A nurse found that Pregnyl 40 is put in the dispensing cart instead of Prefyl 40. She told the
pharmacy and they fixed it. What should the nurse do immediately after?
a. Report in the hospital reporting system
b. Make alert to all of her colleagues for potential patients who have used the drug
c. Apologize to the patient who was about to take it

15. 69. A system response to disruptive behavior may include
a. A policy for dealing with all disruptive staff
b. Direct termination of their jobs
70. A patient should have his right leg amputated. The physician talked to about bilateral amputation
but they agreed to proceed on the right leg only. After surgery they found that they cut the left
leg. What is the appropriate action?
a. Nothing. The patient knows that both needed amputation
b. RCA. It is a sentinel event
71. A nurse mistakenly administered aspirin to the patient instead of acetaminophen. No harm
occurred to the patient. the nurse reported the error to her manager. The nurse has been working
in that hospital for 15 years without any errors. The nurse manager decided not to discuss/study
the error. This action is considered:
a. At-risk behavior
b. Severity bias
c. Non-punitive response
d. Just culture
72. To increase compliance with the requirements of state reporting, PSP can:
a. Revise policy for reporting severe adverse events
b. Integrate reporting with performance compliance
c. Educate managers on requirements of state reporting
73. Which of the following is an evidence-based approach in improving medication safety?
a. Double check of high risk medications
b. Interruption-free zone for nurses to prepare meds

16. c. Using infusion pumps
74. The results of the staff survey shows that the staff complaints of their management take punitive
action towards error. As a PSP, your recommended action will be:
a. Repeat the survey to validate the data
b. Perform team training
c. Adopt a just and fair culture
75. The critical care team wants an explanation from you as a PSP regarding increasing CLABSI rate.
The best approach is:
a. Review the collected data and identify the gaps
b. Study the recent CLABSI for common causes and performance improvement
76. New equipment is purchased at a unit. The PSP received a report that one of the patient was put
at a noxious event because the staff was unable to identify which alarm was signaling. This is an
example of:
a. Unintended consequence of wrong use of equipment
b. Unpreventable consequence
c. Active error by poor training
77. The best way to engage the staff in patient safety initiatives is
a. Share stories that took place in the unit with root causes and action plan
b. Let the clinicians involved in an event to tell their story
c. Display the adverse events data from reports
78. The physician dashboard may include
a. PS initiatives related to specialties
b. Physician specific issues
c. Report with unblended results

17. 79. The best way to get maximum benefit from industry alerts is
a. Subscribe to their notification alerts
b. Review the organizational policy for responding to alerts
80. To increase the effectiveness of communicating information regarding alerts:
a. Use portal and …?... for real-time communication
b. Use pharmacy warehouse and inventory software
81. The PSP wants to collect data about patient-clinician communication. Which of the following
could be the source for this information?
a. Patient safety rounds
b. Patient complaints
c. Claims
82. For having a sustained effect/improvement after a RCA:
a. Apply a forcing action
b. Apply a policy
c. Perform training
d. Double-check
83. The best training to deliver to the emergency department staff about PS is:
a. NPSG
b. 1000 Lives campaign
c. AHRQ PSI

18. 84. TABLE: Crude wound rate is 8.4%
Type of wound
infection
Number of infections Patient census (Number/pt.census)%
Clean
Clean contaminated
Contaminated
Infected
To better evaluate the wound infection rate data,use:
a. Stratification
b. ANOVA
c. Variance analysis
85. For two years, nurses have reported 100 errors while 10 reports were received from physicians.
Last year,300 reports were received from nurses versus 40 from physicians. All reports were
mainly received from ICU and ER departments. As a PSP,what is the recommended action?
a. Find causes of increased errors in ICU and ER
86. A new system for reporting errors was piloted in a hospital. You found that it takes the people 10
minutes for entering the data. As a PSP, what do you recommend?
a. Train the staff on entering the data faster
b. Make it shorter (remove unnecessary fields)
c. Make not all fields mandatory
87. Ideas : sources of data-feedback on reports-connect improvements to survey results
GOOD LUCK 