CPHQ Patient Safety Principles 2 — Questions and Answers
Question 1: Which safety culture concept describes the degree to which staff feel safe reporting errors without fear of punishment?
- Just culture
- Psychological safety
- Non-punitive reporting environment (Correct answer)
- Safety climate
Correct answer: Non-punitive reporting environment
A non-punitive reporting environment specifically refers to staff confidence that reporting errors will not result in retaliation or punishment.
Question 2: A nurse administers the wrong dose because a pharmacist misread a handwritten order. Which error type best describes the pharmacist's action?
- Violation
- Slip
- Lapse
- Mistake (Correct answer)
Correct answer: Mistake
A mistake is a knowledge- or rule-based error where the intended action is wrong, as in misinterpreting an order.
Question 3: The 'iceberg model' of safety events suggests that for every serious patient harm event there are many more:
- Root causes identified
- Near misses and unsafe conditions (Correct answer)
- Adverse drug events
- Sentinel events reported to The Joint Commission
Correct answer: Near misses and unsafe conditions
The iceberg model illustrates that serious harms are the visible tip, while near misses and unsafe conditions are the much larger hidden base.
Question 4: Which human factors principle reduces reliance on memory to prevent medication errors?
- Double-loop learning
- Forcing functions
- Cognitive aids and checklists (Correct answer)
- Normalization of deviance
Correct answer: Cognitive aids and checklists
Cognitive aids and checklists reduce memory dependency by providing step-by-step prompts during complex or high-risk tasks.
Question 5: During a sentinel event analysis, the team identifies that the call-back policy for critical lab values was unclear. This is best categorized as a:
- Latent failure (Correct answer)
- Active failure
- Near miss
- Adverse event
Correct answer: Latent failure
Latent failures are systemic, organizational weaknesses—such as unclear policies—that remain dormant until combined with other factors to cause harm.
Question 6: Which metric is MOST useful for identifying harm trends over time in an inpatient setting?
- Patient satisfaction scores
- Global Trigger Tool (GTT) harm rate (Correct answer)
- Number of complaints received
- Staff turnover rate
Correct answer: Global Trigger Tool (GTT) harm rate
The IHI Global Trigger Tool measures the rate of adverse events per 1,000 patient days and is validated for tracking inpatient harm trends.
Question 7: A patient falls while ambulating because the bed alarm was silenced by staff. Which contributing factor does this most represent?
- Equipment failure
- Workaround behavior (Correct answer)
- Communication breakdown
- Patient non-compliance
Correct answer: Workaround behavior
Silencing alarms inappropriately is a workaround—a deviation from standard procedure that bypasses a safety control.
CPHQ Patient Safety Principles 2
Which safety culture concept describes the degree to which staff feel safe reporting errors without fear of punishment?