Culture
20%of exam
Just CulturePsychological SafetyLeadership WalkRoundsSecond Victim
Systems + Human Factors + Design
20%of exam
SEIPS ModelSwiss Cheese ModelHigh ReliabilityError Types
Safety Risks + Responses
35%of exam
Performance Measurement
25%of exam
Quick Facts
- Exam
- CPPS
- Credential
- Patient safety professional
- Questions
- 120 (100 scored)
- Time
- 2.5 hours
- Pass score
- 500 of 800
- Format
- Computer-based, 4-option MCQ
- Level
- Intermediate to advanced
- Blueprint
- Sept 2024 outline
Just Culture Algorithm
Console error, coach risk, discipline reckless
Human error: consoleAt-risk: coachReckless: discipline
Just Culture vs Blame Culture
Just Culture
- System-focused
- Fair accountability
- Encourages reporting
Blame Culture
- Person-focused
- Punitive response
- Suppresses reporting
System view vs blame view
Just Culture Response
- Inadvertent slip occurs→Console the individual
- Risk was not perceived→Coach at-risk behavior
- Conscious disregard of risk→Discipline reckless behavior
- System flaw is found→Redesign the process
Culture Of Safety
- Just Culture
- Console, coach, discipline
- Psychological Safety
- Safe to speak up
- Learning Culture
- Analyze events, adapt system
- Reporting Culture
- No-blame incident reporting
- Safety Climate
- Point-in-time staff perception
- Non-Hierarchical Culture
- Flat power distance
- Transparency
- Open, honest error disclosure
Leadership + Outreach
- Leadership WalkRounds
- Frontline safety conversations
- Storytelling
- Patient story drives change
- Business Case
- Links safety to ROI
- Executive Sponsor
- C-suite safety champion
- Board Reporting
- Safety metrics reach board
- Second Victim
- Support staff after harm
- Disclosure
- Timely, honest event communication
- Family Engagement
- Patients join safety teams
HRO Five Principles
Preoccupation, reluctance, sensitivity, commitment, deference
Preoccupied with failureReluctant to simplifySensitive to operationsCommitted to resilienceDefers to expertise
Slip vs Mistake
Slip/Lapse
- Correct plan
- Wrong execution
- Unintentional
Mistake
- Wrong plan
- Correct execution
- Knowledge gap
Execution vs planning failure
Systems Thinking Models
- SEIPS
- Person, tasks, tools, environment
- Swiss Cheese Model
- Aligned holes cause harm
- HRO
- Mindful of failure, always
- Safety-I
- Focus on what fails
- Safety-II
- Focus on what works
- Resilience Engineering
- System adapts to variation
- Sociotechnical System
- People plus technology interact
SEIPS System Elements
Person, tasks, tools, environment, organization interact
Person performs taskTools and technologyPhysical environment mattersOrganizational context shapes work
Error vs Violation
Error
- Unintentional
- Slip or mistake
- Console or coach
Violation
- Intentional deviation
- Reckless disregard
- Discipline
Unintended vs deliberate
Human Factors + Error Types
- Slip
- Correct plan, wrong execution
- Lapse
- Memory-based execution failure
- Mistake
- Wrong plan, correct execution
- Violation
- Intentional deviation from rule
- Active Failure
- Sharp-end unsafe act
- Latent Condition
- Hidden system design flaw
- Cognitive Bias
- Flawed mental shortcut
- Normalized Deviance
- Drift becomes accepted norm
- Forcing Function
- Design blocks wrong action
- Sharp End
- Frontline point of care
- Blunt End
- Organizational, system-level decisions
Safety-I vs Safety-II
Safety-I
- Count failures
- Eliminate causes
- Reactive lens
Safety-II
- Study successes
- Build capacity
- Proactive lens
Failure-focus vs success-focus
SBAR Handoff
Situation, Background, Assessment, Recommendation
Situation: what's happeningBackground: relevant historyAssessment: your judgmentRecommendation: what you need
FMEA vs RCA
FMEA
- Proactive
- Before failure
- Predicts risk
RCA
- Reactive
- After event
- Explains cause
Prevent vs investigate
Risk Analysis Tool Picker
- Before the event happens→FMEA(Proactive)
- After the event happens→RCA(Reactive)
- Need a quick review→Apparent cause analysis
- Need a why chain→5 Whys
- Need a failure score→RPN calculation
Risk Analysis Tools
- FMEA
- Proactive failure-mode analysis
- RPN
- Severity x occurrence x detection
- RCA
- Reactive root-cause analysis
- 5 Whys
- Ask why five times
- Apparent Cause Analysis
- Quick, less rigorous review
- Proactive Analysis
- Before the event occurs
- Reactive Analysis
- After the event occurs
Near Miss vs Sentinel Event
Near Miss
- No harm reached
- Caught in time
- Learning opportunity
Sentinel Event
- Death or severe harm
- Mandatory reporting
- Root cause required
No harm vs severe harm
Communication Tool Picker
- Shift handoff→SBAR
- Concern being ignored→CUS words
- Before high-risk procedure→Time out
- Verbal order given→Read-back
- Order seems wrong→Two-challenge rule
Event Classification
- Near Miss
- Caught before reaching patient
- Sentinel Event
- Death or severe harm
- Never Event
- Preventable, serious, reportable event
- Adverse Event
- Harm from care, not disease
- HAC
- Preventable hospital-acquired condition
- Close Call
- Synonym for near miss
HAI Prevention
- CLABSI
- Central-line bloodstream infection
- CAUTI
- Catheter-associated urinary infection
- SSI
- Surgical site infection
- Central Line Bundle
- Checklist prevents CLABSI
- Hand Hygiene
- First-line infection prevention
- Universal Protocol
- Prevents wrong-site surgery
Medication Safety
- Five Rights
- Patient, drug, dose, route, time
- LASA
- Look-alike, sound-alike drugs
- Med Reconciliation
- Compare meds at transitions
- High-Alert Medications
- Highest harm if misused
- Smart Pumps
- Dose error-reduction software
- Polypharmacy
- Over- or under-treatment risk
Communication Tools
- SBAR
- Situation, background, assessment, recommendation
- TeamSTEPPS
- AHRQ teamwork training program
- CUS Words
- Concerned, uncomfortable, safety issue
- Two-Challenge Rule
- Speak up twice, minimum
- Time Out
- Pre-procedure verification pause
- Handoff
- Structured transition of care
- Read-Back
- Confirm verbal order accuracy
PDSA Cycle
Plan, Do, Study, Act
Plan the testDo small scaleStudy the dataAct on results
Process vs Outcome Measure
Process Measure
- Steps followed
- Faster feedback
- Easier to change
Outcome Measure
- Patient result
- Harder to move
- Lagging signal
Doing right vs result
Improvement Method Picker
- Rapid small-scale test→PDSA cycle
- Need aim plus measures→Model for Improvement
- Cut process waste→Lean
- Reduce defect variation→Six Sigma
- Unit-based safety culture→CUSP
- Track process over time→Run chart
Improvement Methods
- PDSA
- Plan, Do, Study, Act
- Model For Improvement
- Three questions plus PDSA
- Lean
- Eliminate waste, add value
- Six Sigma
- Reduce process defects
- CUSP
- Comprehensive unit safety program
- Small Tests Of Change
- Rapid-cycle pilot testing
Measurement + Data
- Process Measure
- Are steps being followed
- Outcome Measure
- Did the patient improve
- Balancing Measure
- Unintended downstream effects
- Run Chart
- Data over time, no limits
- Control Chart
- Data with statistical limits
- SPC
- Statistical process control method
- Leading Indicator
- Predicts future performance
- Lagging Indicator
- Reports past performance
- PSI-90
- AHRQ patient safety composite
- Common Formats
- AHRQ standardized event reporting
Common Traps
Slip vs mistake
Slip is unintentional ≠ Mistake is planning error
Near miss vs sentinel
Near miss no harm ≠ Sentinel event severe harm
FMEA vs RCA timing
FMEA works before failure ≠ RCA works after failure
Culture vs climate
Culture is enduring values ≠ Climate is point-in-time snapshot
Process vs outcome measure
Process measures the steps ≠ Outcome measures the result
Leading vs lagging indicator
Leading predicts future risk ≠ Lagging reports past performance
Just culture vs no-fault
Just culture holds accountability ≠ No-fault ignores behavior choice
Last Minute
- 1.120 questions, 100 scored total
- 2.2.5 hours to complete exam
- 3.Passing score 500 of 800
- 4.Safety Risks domain weighs 35%
- 5.Console errors, coach risk, discipline
- 6.FMEA is proactive, RCA reactive
- 7.SEIPS links people, tools, tasks, environment
- 8.PDSA: Plan, Do, Study, Act
- 9.SBAR structures handoff communication
- 10.Retake wait is 30 days first
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