CPPS Exam Prep 9-Week Study Plan

Week 1, Part I: Patient Safety as a Discipline

Difficulty: Light–Moderate

What it covers:

• Modern patient safety origins: the 1999 IOM report To Err Is Human and the rise of safety science as a recognized discipline

• The foundational vocabulary every CBPPS question rests on: error, harm, adverse event, preventable adverse event, no-harm event, and near miss

• The Swiss Cheese Model of accident causation, active failures vs. latent conditions

• James Reason's Person Approach vs. System Approach to error

• The scientific underpinnings of patient safety: human factors, high-reliability principles, just culture

• The WHO Global Patient Safety Action Plan 2021–2030 and how safety frameworks shape day-to-day clinical decisions

Print: 1 Mind Map, 2 Comparison Charts, 2 Cornell Notes pages

Study Tasks

☐ Read the Study Guide first. Complete the High-Yield Objectives, Key Terms and Definitions, and Concept Overview sections before opening the chapter.

☐ Highlight as you read. Follow the Made Easy Highlighting System

☐ Lock in the six foundational definitions before anything else, because most missed Part I questions come from confusing them. Error is the failure of a planned action to be completed as intended, or use of a wrong plan. Adverse event is injury caused by medical management rather than by the underlying disease. Preventable adverse event is an adverse event attributable to error or to a failure to follow accepted practice. No-harm event is an error that reached the patient without injury. Near miss is an error that did not reach the patient. The single most-tested distinction is near miss vs. no-harm event: same error, different distance from the patient.

☐ Master the Swiss Cheese Model in one sitting. Active failures are unsafe acts at the sharp end (the clinician directly interacting with the patient). Latent conditions are the upstream system weaknesses (staffing, workflow design, policy, scheduling, equipment) that create the holes the active failure passes through. Be ready to identify both in a scenario question and to explain why a "blame the individual" response misses the latent conditions entirely.

☐ Compare Reason's Person Approach and System Approach to error. The Person Approach treats unsafe acts as individual carelessness and responds with discipline, retraining, and naming; it dominates traditional clinical culture and predicts under-reporting. The System Approach treats unsafe acts as consequences of latent conditions and responds by redesigning the system; it underpins every framework in the rest of this book. This distinction is the conceptual bridge into Just Culture in Part II.

☐ Build a one-page summary of the WHO Global Patient Safety Action Plan 2021–2030: its vision of "a world in which no one is harmed in health care," its seven strategic objectives, and its role in shaping national and organizational safety plans.

☐ Complete the Practice Questions for Part I in your quiz bank. Review every rationale, correct and incorrect.

How to Use Your Templates

☐ Mind Map: Central node = Patient Safety as a Discipline. Main branches: History of the Patient Safety Movement (To Err Is Human, evolution of safety science); Core Vocabulary (error, harm, adverse event, preventable adverse event, no-harm event, near miss); Swiss Cheese Model (active failures, latent conditions); Person Approach vs. System Approach; Scientific Foundations (human factors, high-reliability principles, just culture); WHO Global Patient Safety Action Plan 2021–2030.

Comparison Charts:

☐ Chart 1, Near Miss vs. No-Harm Event vs. Adverse Event vs. Preventable Adverse Event: Did the error reach the patient? Was there injury? Was it preventable? Reporting expectation, and one clinical example of each.

☐ Chart 2, Person Approach vs. System Approach: Underlying assumption about why errors happen, typical organizational response, effect on reporting culture, strengths, limitations, and where each one still shows up in practice today.

Cornell Notes:

☐ Page 1 cue questions: What are the six foundational patient safety terms (error, harm, adverse event, preventable adverse event, no-harm event, near miss), and how do you tell them apart in a clinical scenario? What was the central claim of To Err Is Human, and why was 1999 the inflection point for patient safety as a discipline?

☐ Page 2 cue questions: What is the Swiss Cheese Model, and what is the difference between an active failure and a latent condition? What is the central difference between the Person Approach and the System Approach to error, and why does the System Approach predict better safety outcomes?

Week 2, Part II: Culture of Safety

Difficulty: Moderate

What it covers:

• Reason's five interlocking subcultures of safety: just, reporting, learning, informed, and flexible

• The Just Culture algorithm: classifying behavior as human error, at-risk behavior, or reckless behavior, and selecting the proportionate response

• Psychological safety and the specific leadership behaviors that build it

• Non-punitive reporting systems and the feedback loop back to frontline staff

• Leadership and governance accountabilities: executive walkrounds, board-level oversight, visible commitment

• AHRQ Hospital Survey on Patient Safety Culture (HSOPS) and converting culture data into action plans

• Disruptive behavior, burnout, and the second-victim phenomenon as direct threats to patient safety

• Health equity as a patient safety imperative

Print: 1 Mind Map, 3 Comparison Charts, 2 Cornell Notes pages

Study Tasks

☐ Read the Study Guide first. Complete the High-Yield Objectives, Key Terms and Definitions, and Concept Overview sections before opening the chapter.

☐ Highlight as you read using the Made Easy Highlighting System (Red, Purple, Orange, Yellow, Green, Blue, as defined in Week 1).

☐ Walk through the Just Culture algorithm until you can apply it to any clinical scenario. The algorithm sorts a behavior into one of three buckets. Human error is an inadvertent slip, lapse, or mistake; the response is to console and to fix the system. At-risk behavior is a behavioral choice where the actor underestimates the risk or believes the risk is justified (most workarounds live here); the response is to coach and to remove the incentive for the workaround. Reckless behavior is a conscious disregard of substantial and unjustifiable risk; the response is accountability, up to and including discipline. Substitution, foreseeability, and behavioral-choice tests are the three diagnostic questions the algorithm asks. Expect a scenario question on every practice test that hinges on telling at-risk apart from reckless.

☐ Memorize Reason's five subcultures: a Just Culture (proportionate response to behavior), a Reporting Culture (staff report errors and near misses because they feel safe to), a Learning Culture (the organization actually changes in response to reports), an Informed Culture (leaders know the state of safety in real time), and a Flexible Culture (the team can reconfigure itself for the situation). Together these produce what Reason calls an "informed culture."

☐ Define psychological safety in operational terms: the shared belief that the team is safe for interpersonal risk-taking (asking questions, admitting mistakes, raising concerns) without fear of humiliation or retaliation. Know the specific leadership behaviors that build it (inviting input by name, framing work as learning, modeling fallibility, responding productively to bad news) and the behaviors that destroy it (interrupting, shooting the messenger, public correction).

☐ Build a one-page reference for AHRQ HSOPS survey administration and interpretation. Know the composite domains, the recommended administration frequency (typically every 12 to 24 months), benchmarking against the national database, and the structured process of converting low-scoring composites into a prioritized action plan with named owners.

☐ Understand the second-victim phenomenon. The first victim is the patient and family. The second victim is the clinician traumatized by involvement in the adverse event. The third victim is the organization itself. Know the standard structured peer-support response (often the forYOU or RISE model) and the specific risks of suicidal ideation, attrition, and PTSD-like symptoms when no support is offered.

☐ Complete the Practice Questions for Part II in your quiz bank. Review every rationale, correct and incorrect.

How to Use Your Templates

☐ Mind Map: Central node = Culture of Safety. Main branches: Reason's Five Subcultures (just, reporting, learning, informed, flexible); Just Culture Algorithm (human error, at-risk, reckless); Psychological Safety; Non-Punitive Reporting Systems; Leadership Accountabilities (executive walkrounds, board oversight, visible commitment); AHRQ HSOPS; Disruptive Behavior & Burnout; Second-Victim Phenomenon; Health Equity in Safety.

Comparison Charts:

☐ Chart 1, Human Error vs. At-Risk Behavior vs. Reckless Behavior: Definition, mental state of the actor, typical clinical example, organizational response under the Just Culture algorithm, and the diagnostic question that distinguishes it from the other two.

☐ Chart 2, Reason's Five Subcultures: Definition of each, observable staff behaviors when the subculture is healthy, observable behaviors when it is degraded, and the leader's primary job for each.

☐ Chart 3, First Victim vs. Second Victim vs. Third Victim: Who each is, the primary harm they experience, the organization's obligation to each, and one structured support response that addresses each.

Cornell Notes:

☐ Page 1 cue questions: Walk through the Just Culture algorithm from start to finish: what are the three behavior categories, what test distinguishes each, and what is the proportionate response? What is psychological safety in a clinical team, and which three leadership behaviors most reliably build it?

☐ Page 2 cue questions: What does the AHRQ HSOPS measure, and how is a low-scoring composite translated into an action plan? What is the second-victim phenomenon, and what three risks does an unsupported second victim face?

Week 3, Part III: Systems Thinking and Human Factors Engineering

Difficulty: Heavy

What it covers:

• Healthcare as a complex adaptive system, and why linear cause-and-effect reasoning fails to capture clinical work

• Perrow's Normal Accident Theory: interactive complexity and tight coupling as predictors of catastrophic failure

• The five principles of a High-Reliability Organization (HRO) and how each operationalizes in a clinical setting

• Safety-I vs. Safety-II: counting failures vs. understanding everyday success

• SEIPS 1.0 and SEIPS 2.0: work system, processes, outcomes, and the patient as co-producer of work

• Cognitive biases that drive diagnostic and treatment error: anchoring, availability, confirmation, fixation

• Performance limiters: fatigue, workload, interruption, alarm and alert fatigue, automation bias

• The hierarchy of effective design (forcing functions through well-designed checklists), and the phenomenon of normalization of deviance

Print: 1 Mind Map, 4 Comparison Charts, 3 Cornell Notes pages

Study Tasks

☐ Read the Study Guide first. Complete the High-Yield Objectives, Key Terms and Definitions, and Concept Overview sections before opening the chapter.

☐ Highlight as you read using the Made Easy Highlighting System (Red, Purple, Orange, Yellow, Green, Blue, as defined in Week 1).

☐ Lock in the five HRO principles before anything else in this Part. Preoccupation with failure: treat any anomaly, however small, as a window into a weakening defense. Reluctance to simplify interpretations: resist easy explanations; assume the situation is more complex than the first read suggests. Sensitivity to operations: leaders stay close to the frontline work in real time. Commitment to resilience: invest in the team's ability to detect, contain, and bounce back from error. Deference to expertise: in the moment, decision-making moves to the person with the most relevant knowledge, not the highest title. Every HRO question on the CBPPS tests one of these five, usually framed as a scenario.

☐ Understand the Safety-I vs. Safety-II shift. Safety-I defines safety as the absence of adverse events and learns by investigating things that went wrong. Safety-II defines safety as the presence of successful operations and learns by studying how clinicians adapt to make things go right under variable conditions. Safety-II does not replace Safety-I; it complements it. Be ready to identify each in a measurement strategy: counting falls is Safety-I; observing how nurses prevent falls during a busy shift is Safety-II.

☐ Walk through the SEIPS 2.0 model until you can name every block. The work system has five elements: persons, tasks, tools and technology, internal environment, and external environment, plus organizational conditions. The work system shapes processes, which produce outcomes (patient, employee, organizational). SEIPS 2.0 adds collaborative work and the patient as co-producer of work. Use SEIPS to structure any analysis of why a clinical process is unreliable.

☐ Master the hierarchy of effective design from strongest to weakest action. Forcing functions physically prevent the wrong action (you cannot start the infusion until you scan the patient). Constraints limit available options. Standardization reduces unwanted variation. Simplification reduces step count and cognitive load. Well-designed checklists support memory and team coordination. Below this hierarchy sit the weaker actions: warnings, training, and policy memos. The action hierarchy from Part V is the same idea applied to RCA² recommendations.

☐ Map each of the four major cognitive biases to a clinical pattern. Anchoring is over-weighting the first piece of information (the triage chief complaint that frames the whole workup). Availability is judging probability by ease of recall (over-diagnosing the thing you saw last week). Confirmation bias is selectively seeking data that supports the working diagnosis. Fixation is locking onto one diagnosis and missing competing data. Pair each with one countermeasure: structured time-outs, differential diagnosis discipline, diagnostic momentum check, and explicit re-evaluation triggers.

☐ Define normalization of deviance: the gradual acceptance of small deviations from safe practice until the deviation becomes the new norm. Common examples include scrub technique drift, time-out shortcuts, alarm silencing, and skipped read-backs. The defense is active observation, peer feedback, and HRO-style sensitivity to operations.

☐ Complete the Practice Questions for Part III in your quiz bank. Review every rationale, correct and incorrect.

How to Use Your Templates

☐ Mind Map: Central node = Systems Thinking and Human Factors Engineering. Main branches: Complex Adaptive Systems; Normal Accident Theory (interactive complexity, tight coupling); Five HRO Principles; Safety-I vs. Safety-II; SEIPS 1.0 and SEIPS 2.0 (work system, processes, outcomes, patient as co-producer); Cognitive Biases (anchoring, availability, confirmation, fixation); Performance Limiters (fatigue, workload, interruption, alarm fatigue, automation bias); Hierarchy of Effective Design; Normalization of Deviance.

Comparison Charts:

☐ Chart 1, The Five HRO Principles: Name, one-sentence definition, observable behavior when present, observable behavior when absent, and one clinical example of operationalizing it.

☐ Chart 2, Safety-I vs. Safety-II: Definition of safety, what the organization counts, how it learns, what data sources it uses, and a representative clinical example.

☐ Chart 3, Hierarchy of Effective Design (Strongest to Weakest): Forcing function, constraint, standardization, simplification, checklist, then weaker actions (warning, training, policy memo). Definition, clinical example, and approximate strength rating for each.

☐ Chart 4, Anchoring vs. Availability vs. Confirmation vs. Fixation Bias: Definition, characteristic clinical scenario, dominant cognitive mechanism, and the countermeasure that most directly disrupts it.

Cornell Notes:

☐ Page 1 cue questions: What makes healthcare a complex adaptive system, and why does linear cause-and-effect reasoning fail to capture it? What are interactive complexity and tight coupling in Normal Accident Theory, and what kinds of clinical settings exemplify each?

☐ Page 2 cue questions: What are the five HRO principles, and what is one observable clinical behavior that demonstrates each? What is the central difference between Safety-I and Safety-II thinking, and how does each shape what an organization measures?

☐ Page 3 cue questions: What are the elements of the SEIPS 2.0 work system, and how does the patient function as a co-producer of work? Rank the hierarchy of effective design from strongest to weakest, and give a clinical example of each level. What is normalization of deviance, and how is it detected?

Week 4, Part IV: Safety Risk Identification

Difficulty: Heavy

What it covers:

• The distinction between proactive and reactive risk assessment and when to use each

• Risk registers and how patient safety risk integrates into enterprise risk management

• Healthcare Failure Mode and Effects Analysis (FMEA): step-by-step execution and the Risk Priority Number (RPN = Severity × Occurrence × Detection)

• Hazard Analysis and Critical Control Points (HACCP) and probabilistic risk assessment as complementary proactive tools

• Environmental hazard assessment: physical, workflow, and ambient conditions

• Care transitions as a high-risk process and the role of structured handoff and reconciliation

• Distinct risk profiles of pediatric, geriatric, and maternal populations

• High-risk clinical settings: ED, OR, ICU, and behavioral health

Print: 1 Mind Map, 4 Comparison Charts, 3 Cornell Notes pages

Study Tasks

☐ Read the Study Guide first. Complete the High-Yield Objectives, Key Terms and Definitions, and Concept Overview sections before opening the chapter.

☐ Highlight as you read using the Made Easy Highlighting System (Red, Purple, Orange, Yellow, Green, Blue, as defined in Week 1).

☐ Anchor the proactive vs. reactive distinction first. Proactive risk assessment looks at how a process could fail before harm occurs (FMEA, HACCP, probabilistic risk assessment, environmental hazard assessment). Reactive risk assessment looks at how a process did fail after harm occurs (RCA², covered in Part V). The CBPPS tests the matching directly: given a safety question, which tool is appropriate?

☐ Walk through a healthcare FMEA step-by-step until you can run it from memory: (1) select a high-risk process, (2) assemble a multidisciplinary team, (3) graphically map the process and its sub-steps, (4) for each step, identify all potential failure modes, (5) for each failure mode, identify causes and effects, (6) score Severity, Occurrence, and Detection on the 1-to-10 scales, (7) multiply for the Risk Priority Number (RPN = S × O × D), (8) prioritize the highest-RPN failure modes for redesign, (9) implement and re-score. Know that detection difficulty raises the RPN: a failure mode you cannot see coming is more dangerous, not less.

☐ Distinguish FMEA from HACCP. FMEA is the dominant healthcare proactive tool, RPN-driven, and centered on failure modes. HACCP comes from food safety, is centered on identifying Critical Control Points where a hazard must be controlled, and is most useful for processes with clearly definable control thresholds (sterile processing, blood bank, pharmacy compounding). Probabilistic risk assessment quantifies the likelihood and consequence of a chain of events and is most often used for environmental and infrastructure risk.

☐ Treat care transitions as the single highest-volume risk process in healthcare. Every shift change, every unit transfer, every discharge, every consultation handoff is an opportunity for an information failure. Know the standard structured tools (I-PASS, SBAR, medication reconciliation at every transition, transitional care models for discharge) and the patient populations at highest transition risk (elderly with polypharmacy, behavioral health, post-surgical, pediatric chronic illness).

☐ Build a one-page reference of the distinct risk profiles of pediatric, geriatric, and maternal populations. Pediatric: weight-based dosing errors, equipment sizing, identification challenges in nonverbal patients. Geriatric: polypharmacy, fall risk, delirium, pressure injury, sensory impairment. Maternal: hemorrhage, hypertensive disorders, sepsis, venous thromboembolism, plus the unique two-patient framing of obstetric care. Each population has a distinct set of harm bundles (Part VII) that follow from these risk profiles.

☐ Map the distinct hazards of the four high-risk settings. Emergency department: time pressure, undifferentiated patients, boarding, interruption density. Operating room: wrong-site/wrong-patient/wrong-procedure events, retained items, fire risk, anesthesia handoffs. ICU: device density, alarm fatigue, polypharmacy, the highest concentration of CLABSI, CAUTI, and VAP risk. Behavioral health: ligature risk, elopement, suicide risk assessment, restraint and seclusion. Each setting has its own characteristic adverse events and its own typical defenses.

☐ Complete the Practice Questions for Part IV in your quiz bank. Review every rationale, correct and incorrect.

How to Use Your Templates

☐ Mind Map: Central node = Safety Risk Identification. Main branches: Proactive vs. Reactive Assessment; Risk Register & Enterprise Risk Management; Healthcare FMEA (steps, RPN = S × O × D); HACCP & Probabilistic Risk Assessment; Environmental Hazard Assessment; Care Transitions & Handoff/Reconciliation; High-Risk Populations (pediatric, geriatric, maternal); High-Risk Settings (ED, OR, ICU, BH).

Comparison Charts:

☐ Chart 1, Proactive vs. Reactive Risk Assessment: Timing relative to harm, primary tools, central question each one asks, and a representative clinical example of when each is the right choice.

☐ Chart 2, FMEA vs. HACCP vs. Probabilistic Risk Assessment: Origin discipline, central concept (failure modes vs. critical control points vs. event-chain probability), scoring or output, and the best-fit clinical use case for each.

☐ Chart 3, High-Risk Settings (ED vs. OR vs. ICU vs. BH): Dominant hazard profile, top three adverse event categories, characteristic system-level defense, and one population most at risk in that setting.

☐ Chart 4, High-Risk Populations (Pediatric vs. Geriatric vs. Maternal): Dominant risk drivers, top three harm categories, characteristic safeguards, and the most heavily tested bundle or protocol associated with each.

Cornell Notes:

☐ Page 1 cue questions: What is the central difference between proactive and reactive risk assessment, and which tools belong to each? What is a risk register, and how does patient safety risk integrate into an enterprise risk management framework?

☐ Page 2 cue questions: Walk through the nine steps of a healthcare FMEA from start to finish. How is the Risk Priority Number calculated, and why does a higher Detection score raise (rather than lower) the RPN?

☐ Page 3 cue questions: Why are care transitions the single highest-volume risk process in healthcare, and what are the two or three structured handoff tools that defend against transition failure? What are the distinct hazards of the ED, OR, ICU, and behavioral health environments, and what is one defining defense for each?

Week 5, Part V: Reactive Investigation and Responses

Difficulty: Heavy

What it covers:

• Detecting adverse events: trigger tools, voluntary reports, and clinical audits, plus selecting the right detection method for the situation

• The sentinel event definition and the mandatory reporting and review requirements that follow

• Root Cause Analysis using the RCA² framework, including the action hierarchy that ranks intervention strength

• Five Whys, fishbone (Ishikawa) diagrams, and process mapping as RCA² supporting techniques

• Integrating human factors analysis into investigations so cognitive, environmental, and design contributors surface

• Common cause analysis across multiple events to identify systemic patterns invisible at the single-case level

• Apparent cause analysis for lower-severity events and the construction of defensible action plans

Print: 1 Mind Map, 3 Comparison Charts, 3 Cornell Notes pages

Study Tasks

☐ Read the Study Guide first. Complete the High-Yield Objectives, Key Terms and Definitions, and Concept Overview sections before opening the chapter.

☐ Highlight as you read using the Made Easy Highlighting System (Red, Purple, Orange, Yellow, Green, Blue, as defined in Week 1).

☐ Lock in the three detection methods and when to use each. Trigger tools are retrospective audits that flag charts containing defined clinical "triggers" (reversal agents, abrupt lab drops, unplanned ICU transfer, naloxone use); they detect harm that voluntary reporting misses. Voluntary reports are submitted by frontline staff and capture cultural and contextual information no chart audit can, but undercount harm by an order of magnitude. Clinical audits compare practice against a defined standard and detect deviation and emerging risk. The CBPPS tests the matching: which method best detects which problem?

☐ Memorize the sentinel event definition: a patient safety event (not primarily related to the natural course of the patient's illness) that reaches a patient and results in death, permanent harm, or severe temporary harm requiring intervention to sustain life. Sentinel events trigger mandatory comprehensive systematic analysis (typically RCA²) within 45 days, and many fall under Joint Commission reporting expectations. Know the canonical sentinel categories: wrong-site/wrong-patient/wrong-procedure, unanticipated death of a full-term infant, suicide of an inpatient, infant abduction, hemolytic transfusion reaction, severe maternal morbidity, retained foreign object.

☐ Walk through RCA² from start to finish. The "squared" is the addition of Actions: every RCA must end with implemented and tracked corrective actions, not just a report. The standard sequence is: convene a multidisciplinary team within 72 hours, build a chronological process flow, identify all proximate (active) causes, ask "why" repeatedly to surface contributing and root causes, evaluate each cause against human factors and system design, draft strong corrective actions, assign owners and dates, and track action completion plus outcome over 12 to 24 months.

☐ Master the action hierarchy before any exam question on RCA² recommendations. From stronger to weaker: architectural and physical plant changes; new devices with usability testing; engineered controls and forcing functions; simplification and standardization; tangible involvement and action by leadership. Weaker actions include warnings and labels, new procedures and policy alone, training, and double checks. A "strong" RCA² recommendation always sits in the top half of this hierarchy. A recommendation made entirely of training, policy, and double checks is, by definition, weak and is the most common reason for repeated sentinel events.

☐ Distinguish Five Whys from fishbone diagrams. Five Whys is iterative depth: ask "why" until you reach a root cause, typically three to seven iterations. Fishbone is structural breadth: lay out contributing factors across categories (people, process, equipment, environment, materials, management). They are complementary, not interchangeable. Process mapping sits alongside both as the diagrammatic backbone of the investigation.

☐ Understand common cause analysis and apparent cause analysis as the bracketing tools around RCA². Common cause analysis aggregates many low-severity events to identify a systemic pattern invisible at the single-case level (recurrent medication errors all sharing one workflow defect). Apparent cause analysis is a shorter, lower-severity investigation that ends at the most likely contributing factor without exhausting every root cause path; it is the right tool for high-volume lower-harm events where a full RCA² would be disproportionate.

☐ Complete the Practice Questions for Part V in your quiz bank. Review every rationale, correct and incorrect.

How to Use Your Templates

☐ Mind Map: Central node = Reactive Investigation and Responses. Main branches: Detection Methods (trigger tools, voluntary reports, audits); Sentinel Events (definition, reporting); RCA² Framework (steps, team, timeline); Five Whys; Fishbone (Ishikawa) Diagrams; Process Mapping; Human Factors Integration; Common Cause Analysis; Action Hierarchy (stronger to weaker); Apparent Cause Analysis.

Comparison Charts:

☐ Chart 1, Trigger Tool vs. Voluntary Report vs. Audit: Detection mechanism, what each finds best, what each misses, typical use cadence, and one canonical example of each.

☐ Chart 2, RCA² vs. Apparent Cause Analysis: Trigger event severity, team composition, depth of cause analysis, output expectations, timeline, and the type of event each is appropriate for.

☐ Chart 3, Action Hierarchy (Stronger to Weaker): Action category (architectural 

change, forcing function, standardization, simplification, leadership involvement, policy, training, double check), strength rating, clinical example, and durability of the protection.

Cornell Notes:

☐ Page 1 cue questions: What is the definition of a sentinel event, and what are the canonical sentinel event categories? Which detection method (trigger tool, voluntary 

report, or audit) is best for which kind of safety problem?

☐ Page 2 cue questions: Walk through the RCA² framework from event identification through action tracking. What is the "squared" in RCA², and what does it require that the original RCA model did not?

☐ Page 3 cue questions: Rank the action hierarchy from stronger to weaker, and give a clinical example at each level. Why is a recommendation built entirely of training and policy considered weak, and what does that predict about recurrence?

Week 6, Part VI: High-Reliability Tools and Communication

Difficulty: Moderate–Heavy

What it covers:

• Structured communication tools: SBAR, I-PASS, closed-loop read-backs

• TeamSTEPPS and its assertion tools: CUS, the Two-Challenge Rule, and DESC

• Crew resource management principles adapted to clinical teams, including briefings, huddles, and debriefings

• Rapid response systems and early warning scores for detecting deterioration

• The Universal Protocol, the surgical time-out, and the WHO Surgical Safety Checklist

• Patient and family engagement as an active partnership in safety

• Disclosure of adverse events done ethically and skillfully

• Communication-and-Resolution Programs, including the CANDOR framework

Print: 1 Mind Map, 3 Comparison Charts, 2 Cornell Notes pages

Study Tasks

☐ Read the Study Guide first. Complete the High-Yield Objectives, Key Terms and Definitions, and Concept Overview sections before opening the chapter.

☐ Highlight as you read using the Made Easy Highlighting System (Red, Purple, 

Orange, Yellow, Green, Blue, as defined in Week 1).

☐ Distinguish SBAR from I-PASS, because the CBPPS tests both directly. SBAR is a four-part framing tool for any concise clinical communication: Situation, Background, Assessment, Recommendation. It is the right tool for a focused phone call, a consult request, or a code-team request. I-PASS is a five-part standardized handoff tool: Illness severity, Patient summary, Action list, Situation awareness and contingencies, Synthesis by receiver. It is the right tool for a shift change, a unit-to-unit transfer, or a multi-patient handoff. Closed-loop read-back layers on top of both: the receiver repeats or paraphrases the message and the sender confirms.

☐ Learn the three TeamSTEPPS assertion tools because every safety-culture scenario question on the CBPPS tests one of them. CUS is the graduated alert language: "I'm Concerned," then "I'm Uncomfortable," then "This is a Safety issue." Two-Challenge Rule: if a team member's concern is not acknowledged the first time, they restate it with the explicit framing that this is the second challenge, and the team must stop and address it. DESC is the structured conflict-resolution script: Describe the behavior, Express how it affects the team, Suggest an alternative, Consequences if the behavior continues.

☐ Walk through the Universal Protocol and WHO Surgical Safety Checklist in order. The Universal Protocol has three required elements: pre-procedure verification of patient and procedure, site marking by the operating practitioner, and a time-out immediately before the procedure with the full team. The WHO Surgical Safety Checklist has three points of pause: Sign In (before anesthesia induction), Time Out (before skin incision), and Sign Out (before the patient leaves the OR). Know which items belong to which point of pause; the most-missed item is sponge, instrument, and needle count, which belongs to Sign Out.

☐ Master the disclosure-and-resolution sequence using the CANDOR framework: Communication, Apology, Negotiation, Disclosure, Observation, Resolution. CANDOR is the operational expression of Communication-and-Resolution Programs (CRPs) and replaces the older "deny and defend" malpractice posture with early, honest disclosure and a coordinated response that addresses the patient, family, second victim, and organizational learning simultaneously.

☐ Operate rapid response systems in the context of a valid early warning score (NEWS2, MEWS, or PEWS in pediatrics). Know the threshold-based activation criteria, the standard composition of the rapid response team (RRT), and the documented reduction in failure-to-rescue events when activation criteria are clear and frontline activation is supported.

☐ Complete the Practice Questions for Part VI in your quiz bank. Review every rationale, correct and incorrect.

How to Use Your Templates

☐ Mind Map: Central node = High-Reliability Tools and Communication. Main branches: Structured Communication (SBAR, I-PASS, closed-loop read-back); TeamSTEPPS Assertion Tools (CUS, Two-Challenge Rule, DESC); Crew Resource Management & Team Events (briefings, huddles, debriefings); Rapid Response Systems & Early Warning Scores (NEWS2, MEWS, PEWS); Universal Protocol & WHO Surgical Safety Checklist (Sign In, Time Out, Sign Out); Patient & Family Engagement; Disclosure of Adverse Events; CANDOR & Communication-and-Resolution Programs.

Comparison Charts:

☐ Chart 1, SBAR vs. I-PASS vs. Closed-Loop Read-Back: Number of components, components named, primary use case (focused call vs. handoff vs. any communication), where each is layered on top of the other, and one canonical clinical example.

☐ Chart 2, CUS vs. Two-Challenge Rule vs. DESC: Trigger situation, structure of the script, who delivers it, and the specific outcome it is designed to produce.

☐ Chart 3, Briefing vs. Huddle vs. Debriefing: Timing relative to the work, purpose, typical duration, who attends, and the safety outcome each one is designed to produce.

Cornell Notes:

☐ Page 1 cue questions: What are the four components of SBAR, and when is SBAR the right tool? What are the five components of I-PASS, and when is I-PASS the right tool? What is closed-loop read-back, and how does it layer on top of both?

☐ Page 2 cue questions: Walk through the three points of pause in the WHO Surgical Safety Checklist and the items that belong to each. What are the six elements of CANDOR, and how does CANDOR differ from the older "deny and defend" approach to adverse events?

Week 7, Part VII: Common Harm Categories

Difficulty: Heavy, High-Yield

What it covers:

• Medication errors, high-alert medications, and the ISMP risk-reduction strategies

• Healthcare-associated infection prevention bundles: CLABSI, CAUTI, VAP, SSI, and Clostridioides difficile

• Patient identification errors and wrong-site/wrong-patient/wrong-procedure events

• Diagnostic safety frameworks for reducing missed, delayed, and incorrect diagnoses

• Multifactorial fall prevention and pressure injury prevention

• Retained surgical items: counts, imaging, and adjunct technology

• Documentation-related harm and acceptable abbreviation practices

• Behavioral health safety: suicide risk identification, ligature reduction, elopement prevention

• Maternal safety bundles: hemorrhage, hypertensive disorders, sepsis, VTE

Print: 1 Mind Map, 4 Comparison Charts, 3 Cornell Notes pages

Study Tasks

☐ Read the Study Guide first. Complete the High-Yield Objectives, Key Terms and Definitions, and Concept Overview sections before opening the chapter.

☐ Highlight as you read using the Made Easy Highlighting System (Red, Purple, Orange, Yellow, Green, Blue, as defined in Week 1).

☐ Memorize the ISMP high-alert medication categories: insulin, anticoagulants (especially heparin and DOACs), opioids, concentrated electrolytes (KCl, hypertonic saline, MgSO₄), neuromuscular blocking agents, chemotherapy, and sedation agents. Know the standard ISMP risk-reduction strategies: standardized concentrations, removal of concentrated electrolytes from floor stock, independent double checks for the highest-risk drugs, smart pump dose-error-reduction software, and barcode medication administration.

☐ Build a one-card summary of every major HAI prevention bundle. CLABSI bundle: hand hygiene, maximal barrier precautions during insertion, chlorhexidine skin antisepsis, optimal site selection (avoid femoral in adults), daily review of line necessity. CAUTI bundle: avoid unnecessary catheterization, aseptic insertion, maintain a closed system, daily assessment of necessity with prompt removal. VAP (ventilator bundle): head of bed elevation 30 to 45 degrees, daily sedation interruption and assessment of readiness to extubate, peptic ulcer prophylaxis, DVT prophylaxis, oral care with chlorhexidine. SSI bundle: appropriate antibiotic prophylaxis timing, hair clipping not shaving, normothermia, glycemic control. C. difficile prevention: antimicrobial stewardship as the single most powerful intervention, contact precautions with soap-and-water hand washing (alcohol does not inactivate spores), environmental cleaning with sporicidal agent.

☐ Walk through the Universal Protocol for wrong-site/wrong-patient/wrong-procedure prevention in order. Pre-procedure verification confirms the right patient, right procedure, right site, with documentation, imaging, and consent at the bedside. Site marking is performed by the practitioner doing the procedure, with an unambiguous mark visible after prep and drape, with patient involvement when possible. The time-out is the final stop immediately before incision, with active participation of the full team. Wrong-site events are still classified as sentinel events.

☐ Treat diagnostic safety as a distinct discipline. The standard categories of diagnostic error are missed, delayed, and incorrect diagnoses. The dominant cognitive contributors are anchoring, availability, premature closure, and confirmation bias (Part III). The dominant system contributors are test result follow-up failure, handoff failure between provider settings, and communication failure between specialists and primary care. SPADE (Symptom-Disease Pair Analysis of Diagnostic Error) and patient-reported diagnostic safety surveys are emerging measurement tools.

☐ Master multifactorial fall prevention and pressure injury prevention because the CBPPS tests both in scenario form. Fall prevention: validated risk assessment on admission and per shift, individualized plan, scheduled toileting, footwear and bedside environment, post-fall huddle. Pressure injury prevention: Braden score on admission and per shift, repositioning schedule, support surface selection, skin assessment, nutritional optimization. Both depend on a multifactorial plan, not any single intervention.

☐ Lock in the four maternal safety bundles from the Alliance for Innovation on Maternal Health (AIM). Obstetric hemorrhage bundle: risk assessment, hemorrhage cart, massive transfusion protocol, response simulation. Severe hypertension in pregnancy bundle: standardized response to BP at or above 160/110, antihypertensive within 30 to 60 minutes. Sepsis in obstetric care bundle: early recognition, source control, antibiotics within one hour. Maternal venous thromboembolism prevention bundle: risk stratification on admission and postpartum, mechanical prophylaxis, pharmacologic prophylaxis when indicated.

☐ Complete the Practice Questions for Part VII in your quiz bank. Review every rationale, correct and incorrect.

How to Use Your Templates

☐ Mind Map: Central node = Common Harm Categories. Main branches: Medication Errors & High-Alert Medications (ISMP); HAI Bundles (CLABSI, CAUTI, VAP, SSI, C. difficile); Patient ID Errors & Wrong-Site Events (Universal Protocol); Diagnostic Safety (missed, delayed, incorrect); Falls; Pressure Injuries; Retained Surgical Items; Documentation-Related Harm & Abbreviations; Behavioral Health Safety (suicide risk, ligature, elopement); Maternal Safety Bundles (hemorrhage, hypertension, sepsis, VTE).

Comparison Charts:

☐ Chart 1, Major HAI Bundles (CLABSI vs. CAUTI vs. VAP vs. SSI vs. C. difficile): Three to five core bundle elements, the single most powerful intervention in each bundle, the patient population at highest risk, and one common implementation pitfall.

☐ Chart 2, ISMP High-Alert Medication Categories & Risk-Reduction Strategies: Drug class, dominant error mechanism, sentinel risk-reduction strategy, the role of independent double checks, and one example of barcode/smart pump defense.

☐ Chart 3, Falls vs. Pressure Injuries vs. Retained Surgical Items: Validated risk assessment tool, three core preventive practices, the team member primarily accountable, and the standard post-event response.

☐ Chart 4, Maternal Safety Bundles (Hemorrhage vs. Hypertension vs. Sepsis vs. VTE): Trigger threshold, time-bound response standard, key bundle elements, and the standard simulation or drill that reinforces the bundle.

Cornell Notes:

☐ Page 1 cue questions: What are the ISMP high-alert medication categories, and what are the four or five standard ISMP risk-reduction strategies that apply across all of them? What are the core prevention bundle elements for CLABSI, CAUTI, VAP, SSI, and C. difficile?

☐ Page 2 cue questions: Walk through the Universal Protocol from pre-procedure verification through time-out. What are the standard categories of diagnostic error, and what are the dominant cognitive and system contributors to each?

☐ Page 3 cue questions: What are the four maternal safety bundles, the trigger threshold for each, and the time-bound response standard expected for each? What are the three behavioral health safety priorities (suicide risk identification, ligature reduction, elopement prevention), and what is one operational defense for each?

Week 8, Part VIII: Performance Measurement, Improvement, and Monitoring

Difficulty: Moderate–Heavy

What it covers:

• The Model for Improvement: the three core questions and the PDSA cycle for testing change in safety practice

• Process, outcome, and balancing measures and how to select the right mix for any improvement project

• Run charts and control charts and the distinction between common-cause and special-cause variation

• Statistical process control applied to ongoing safety monitoring

• Trigger tools including the IHI Global Trigger Tool for population-level harm detection

• Voluntary reporting systems with Patient Safety Organization (PSO) protections, plus national reporting databases like NHSN and MAUDE

• Designing dashboards and scorecards that drive decisions rather than just display data

• Public reporting: strengths, limits, and unintended consequences

Print: 1 Mind Map, 3 Comparison Charts, 2 Cornell Notes pages

Study Tasks

☐ Read the Study Guide first. Complete the High-Yield Objectives, Key Terms and Definitions, and Concept Overview sections before opening the chapter.

☐ Highlight as you read using the Made Easy Highlighting System (Red, Purple, Orange, Yellow, Green, Blue, as defined in Week 1).

☐ Lock in the Model for Improvement before any other content in this Part. Its three core questions: (1) What are we trying to accomplish? (2) How will we know that a change is an improvement? (3) What changes can we make that will result in improvement? Question 1 produces the Aim Statement (specific, measurable, time-bound). Question 2 produces the measures (process, outcome, balancing). Question 3 produces the change ideas, which are then tested with PDSA cycles.

☐ Walk through the PDSA cycle until it is automatic. Plan: state the objective, predict what will happen, plan the test (who, what, when, where), plan the data collection. Do: run the test on a small scale, document observations, capture data. Study: analyze data against the prediction, summarize what was learned. Act: adopt, adapt, or abandon the change, and plan the next cycle. The point of a PDSA cycle is small-scale learning, not implementation. Multiple small PDSA cycles in series build evidence and stakeholder confidence before scale-up.

☐ Distinguish the three measure types because this is heavily tested. Process measures quantify whether the steps that should produce the outcome actually happen (the percentage of central lines placed with the full CLABSI bundle). Outcome measures quantify the result you ultimately care about (CLABSI rate per 1,000 line-days). Balancing measures detect unintended consequences elsewhere in the system (a rise in PICC line use when central line use is restricted). Every improvement project should carry at least one of each.

☐ Master the common-cause vs. special-cause distinction. Common-cause variation is the natural, expected fluctuation built into a stable process; the right response is to redesign the process if the level is unsatisfactory, not to react to individual data points. Special-cause variation is the unusual, identifiable signal that something has changed; the right response is to investigate the specific cause. Treating common-cause variation as if it were special-cause is "tampering" and reliably makes a process worse over time. Control charts identify the difference using control limits, runs, trends, and standard pattern rules.

☐ Build a one-page reference for PSO, NHSN, and MAUDE. Patient Safety Organizations are federally certified entities that collect safety event data under the Patient Safety and Quality Improvement Act, with confidentiality and privilege protections that encourage candid reporting. NHSN (National Healthcare Safety Network, CDC) is the standardized HAI surveillance system; CMS reporting requirements drive most hospital participation. MAUDE (Manufacturer and User Facility Device Experience, FDA) is the medical device adverse event database; device-related events are reportable.

☐ Engage public reporting thoughtfully. Public reporting drives accountability and informs consumer choice, but it carries documented unintended consequences: gaming, risk-aversion behaviors (refusing high-risk patients), measurement noise that masks signal, and disproportionate penalty to safety-net hospitals. A defensible public reporting strategy uses risk-adjusted measures, transparent methodology, and balancing measures that detect gaming or access loss.

☐ Complete the Practice Questions for Part VIII in your quiz bank. Review every rationale, correct and incorrect.

How to Use Your Templates

☐ Mind Map: Central node = Performance Measurement, Improvement, and Monitoring. Main branches: Model for Improvement (three questions, Aim Statement, Driver Diagram); PDSA Cycle; Measure Types (process, outcome, balancing); Run Charts; Control Charts (common-cause vs. special-cause); Statistical Process Control; Trigger Tools (IHI Global Trigger Tool); Voluntary Reporting & PSO Protections; NHSN; MAUDE; Dashboards & Scorecards; Public Reporting.

Comparison Charts:

☐ Chart 1, Process vs. Outcome vs. Balancing Measures: What it counts, what question it answers, an example tied to a CLABSI improvement project, and the dominant pitfall when this measure type is missing from the project.

☐ Chart 2, Run Chart vs. Control Chart: Data structure, what each detects, control-limit construction (only on control charts), pattern rules for special-cause detection, and the best-fit clinical example for each.

☐ Chart 3, PSO vs. NHSN vs. MAUDE: Hosting authority, what each receives, legal protections or reporting obligations, typical user, and the type of safety question each one is best positioned to answer.

Cornell Notes:

☐ Page 1 cue questions: What are the three core questions of the Model for Improvement, and what does each one produce? Walk through the PDSA cycle from start to finish, and explain why the point of a PDSA is small-scale learning rather than full implementation.

☐ Page 2 cue questions: What is the difference between common-cause and special-cause variation, and what is the wrong response to each (tampering vs. failing to investigate)? What is the role of a PSO, what does NHSN report on, and what kinds of events are reportable to MAUDE?

Week 9: Full Review & Exam Simulation

Your final week is not about learning new material. It is about consolidating everything you have built and proving it under exam conditions.

Review Tasks

☐ Re-draw one Mind Map from memory for each Part you feel least confident about. Check it against your original.

☐ Work through your Cornell Notes cue columns for every Part. Cover the right-hand notes and answer from memory.

☐ Re-do any quiz bank questions you got wrong across all Parts. Focus on the rationales.

☐ Review the Common Mistakes, Rapid Review, and Self-Assessment Checklist sections for your two or three weakest Parts. For most candidates, those weak spots cluster in Part III (HRO principles and SEIPS), Part V (action hierarchy strength ranking), and Part VII (telling the bundles apart under time pressure).

Exam Simulation

☐ Take the full-length CBPPS practice exam using the QR code in the back matter of this book. Complete it in one sitting, timed, as close to real exam conditions as possible.

☐ Review your emailed score report. Identify which Parts you missed most and spend your remaining time on those Parts' Rapid Review and clinical scenarios only.