Free CPPS Exam Flashcards

Console the individual rather than punish them, and investigate the system and process factors that allowed the error to occur. Punishing honest mistakes suppresses reporting and hides system-level risks.

Coach the individual — increase risk awareness, remove the incentive to drift from the safe process, and reinforce correct behavior. Coaching, not discipline, addresses behavioral drift.

Discipline is appropriate, because the individual consciously chose to disregard a known, substantial risk. This is the only one of the three behavior types (error, at-risk, reckless) that warrants punitive action.

A shared belief that the team is safe for interpersonal risk-taking — staff can speak up about errors, near misses, or concerns without fear of punishment or humiliation. It is a prerequisite for reliable incident reporting.

A learning culture does not just collect reports — it systematically analyzes events, disseminates findings, and changes the system in response. Reporting without follow-through analysis and action does not improve safety.

Safety climate is a point-in-time snapshot of staff perceptions and attitudes toward safety, usually captured by survey. Safety culture is the deeper, enduring set of shared values, norms, and behaviors that shape how an organization actually manages risk.

The AHRQ Surveys on Patient Safety Culture (SOPS) and the Safety Attitudes Questionnaire (SAQ). Both are used to benchmark culture, target improvement domains, and track change over time.

A structured, transparent process of promptly telling patients and families what happened, apologizing where appropriate, and explaining the steps being taken — contrasted with the historical 'deny and defend' approach, which erodes trust and increases litigation risk.

A healthcare worker who is traumatized by involvement in an unanticipated adverse event. Organizations owe them structured peer support, confidential debriefing, and a non-punitive review process, since staff well-being directly affects future safety performance.

Leaders make visible, regular rounds to front-line units, ask staff directly about safety hazards and near misses, and follow up with visible action. The visibility and follow-through — not just the rounding itself — is what builds trust and reporting.

Safety emerges from the interaction of the work system's elements — person, tasks, tools/technology, environment, and organization — not from any single element in isolation. Redesigning one element without considering its interactions can create new hazards.

The holes represent active failures (sharp-end unsafe acts) and latent conditions (upstream design or management flaws). Harm occurs only when holes in multiple layers momentarily align, letting a hazard trajectory pass through every defense.

(1) Preoccupation with failure, (2) reluctance to simplify interpretations, (3) sensitivity to operations, (4) commitment to resilience, and (5) deference to expertise. HROs treat small anomalies as signals of latent system weakness.

Safety-I focuses on preventing things from going wrong by analyzing failures after the fact (reactive). Safety-II focuses on understanding why things go right most of the time, so the system can adapt under varying conditions (proactive, resilience-based).

The gradual acceptance of an unsafe shortcut as 'normal' because nothing bad happened the first few times it was used. It is dangerous because risk quietly accumulates until an accident trajectory finally lines up with a rare failure.

A hard physical or software constraint that makes it impossible, not just difficult, to complete an unsafe action — e.g., an IV connector that cannot physically attach to an oxygen line. Forcing functions are a 'strong' safety intervention because they do not rely on human vigilance.

They all reduce a clinician's working-memory capacity and attentional resources, raising the likelihood of slips, lapses, and missed steps. Human factors engineering designs workflows to reduce these demands rather than expecting perfect vigilance.

Human error is inadvertent, with no intent and no risk perceived. At-risk behavior is a conscious drift where the risk is not recognized as substantial. Reckless behavior is a conscious, unjustifiable disregard of a known substantial risk. The distinction drives whether the response is console, coach, or discipline.

How easily and accurately a user can operate a device or system as intended under real working conditions. Poor usability, such as confusing alarms or lookalike interfaces, creates latent conditions that set clinicians up to fail regardless of skill or vigilance.

To build systems that can anticipate, monitor, respond to, and learn from both expected and unexpected disruptions — sustaining safe performance even as conditions vary, rather than relying solely on rigid, static procedures.

Proactive (prospective) — it identifies and scores potential failure modes for a process before an event occurs, so a team can redesign high-risk steps preemptively.

RPN = Severity x Occurrence x Detectability. Higher RPNs, meaning a worse outcome, more frequent occurrence, and harder detection, get prioritized first for redesign.

Reactive (retrospective) — it is triggered after an adverse event, sentinel event, or serious near miss, working backward to find the underlying system causes rather than just the proximate cause.

FMEA analyzes a process before failure happens, for prevention. RCA analyzes an event after it happened, for investigation. Teams often use both — RCA findings can even trigger a targeted FMEA on the redesigned process.

It places explicit emphasis on identifying strong, sustainable corrective actions, not just root causes, and on measuring whether those actions actually reduced risk — addressing the common failure of RCAs that produce findings but no lasting fix.

Strongest to weakest: forcing functions/automation, then double-checks/redundancy, then training, policy, and reminders. Interventions that do not depend on human memory or vigilance are the most reliable.

An event or situation that could have resulted in harm but did not, either by chance or through timely intervention. Near misses are treated as valuable, low-cost warning signals of latent system weakness.

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, that is unrelated to the natural course of the patient's illness. It demands immediate investigation and response, typically an RCA.

A serious, largely preventable adverse event that should never occur if safety systems function correctly — for example, wrong-site surgery or a retained surgical instrument. The National Quality Forum maintains a formal list of these 'serious reportable events.'

Hand hygiene, maximal sterile barrier precautions at insertion, chlorhexidine skin antisepsis, optimal catheter site selection, and daily review of line necessity with prompt removal when no longer needed.

Insert catheters only for validated indications, use aseptic insertion technique, maintain a closed sterile drainage system, and review necessity daily to remove the catheter as soon as it is no longer needed.

Appropriately timed prophylactic antibiotics, appropriate hair removal by clipping rather than shaving, maintenance of perioperative normothermia and glycemic control, and skin antisepsis with an appropriate agent.

A standardized handoff and escalation format: Situation, Background, Assessment, Recommendation. It reduces ambiguity in urgent clinician-to-clinician communication, a major contributor to sentinel events.

An evidence-based teamwork system from AHRQ and the Department of Defense, built around four core competencies: leadership, situation monitoring, mutual support, and communication — designed to improve team performance and reduce errors in high-risk clinical settings.

'I am Concerned, I am Uncomfortable, this is a Safety issue' is a scripted escalation phrase that gives any team member, regardless of hierarchy, a clear, unambiguous way to stop unsafe action. It flattens hierarchy-driven communication failures.

Information can be lost, distorted, or omitted each time responsibility for a patient transfers between providers, shifts, or care settings. Standardized handoff tools, like SBAR, exist specifically to close this gap.

The Beers Criteria lists medications that carry elevated risk in older adults and should generally be avoided or used with caution. High-alert medications, such as anticoagulants, insulin, opioids, and concentrated electrolytes, are a broader category of drugs that cause disproportionate harm when used in error, warranting extra safeguards like independent double-checks.

Plan (design a small test of change), Do (carry it out), Study (analyze the results against predictions), Act (adopt, adapt, or abandon the change) — a rapid-cycle test-and-learn approach to improvement.

(1) What are we trying to accomplish? (2) How will we know a change is an improvement? (3) What change can we make that will result in improvement? These questions set the aim, measures, and change ideas before testing begins.

A run chart plots data over time against the median to visually detect non-random patterns or trends. A control chart adds statistically calculated upper and lower control limits, letting a team formally distinguish common-cause variation from special-cause variation.

Common-cause variation is routine, expected 'noise' inherent to a stable process — improving it requires redesigning the whole system. Special-cause variation is an unusual, assignable signal, such as a single outlier event, that warrants investigating that specific cause.

Process measures track whether the steps intended to produce the outcome are actually being followed, such as hand-hygiene compliance rate. Outcome measures track the ultimate result, such as infection rate. Balancing measures check whether the change caused unintended harm elsewhere in the system.

Quality can be assessed through three linked categories: structure (resources, staffing, facilities), process (what is actually done in care delivery), and outcome (the resulting effect on patient health). Each level should be examined, not just outcomes alone.

Aggregate rates can mask important differences between units, shifts, patient populations, or providers. Stratifying the data reveals where a problem is concentrated so improvement efforts can be targeted rather than applied uniformly.

A leading indicator predicts future risk and can be acted on proactively, such as near-miss reports or safety rounds completed. A lagging indicator reflects harm that has already occurred, such as infection rate or mortality. Effective programs track both.

Formal change management: standardizing the new process, training staff, building in ongoing monitoring and audit, and adjusting incentives or workflows so the old at-risk behavior does not quietly creep back in.

Skills to scope and sequence a project, engage and align a multidisciplinary team, run effective meetings, manage resistance to change, and keep stakeholders informed. Technical tools like PDSA fail without these skills to drive adoption.

Continue tracking the relevant process, outcome, and balancing measures after go-live to confirm the improvement holds over time and has not introduced a new problem — improvement is not complete at implementation, only at sustained verification.

They standardize how patient safety events are defined, collected, and reported across organizations, enabling valid internal trending and external benchmarking against national safety performance.

The nature of the problem and the team's goal. PDSA suits rapid, small-scale tests of an idea; Lean targets waste and flow in a process; Six Sigma targets reducing variation in a high-volume process with strong statistical control needs.