Certified Professional in Patient Safety (CPPS) Practice Exam

What action should a healthcare organization take when a medication error occurs to identify the underlying cause?

1. Conduct a root cause analysis.

2. Restrict access to the affected medication.

3. Increase staffing levels immediately.

4. Reinforce training on medication administration.

The correct answer is: Conduct a root cause analysis.

Conducting a root cause analysis is an essential action for a healthcare organization when a medication error occurs because it systematically investigates the underlying issues that contributed to the error. This method involves gathering information, identifying contributing factors, and analyzing the sequence of events that led to the error. By understanding the systemic problems, rather than just focusing on individual mistakes or reinforcing surface-level training, organizations can implement effective interventions aimed at preventing similar errors in the future. In contrast, restricting access to the affected medication may not address the root causes of why the error occurred. Simply increasing staffing levels might provide temporary relief but does not guarantee that errors will not happen again if underlying issues are not identified and addressed. Likewise, reinforcing training on medication administration without first understanding the causes of the error may not be effective; it assumes that the error was due solely to a lack of knowledge or skills rather than potential systemic or process-related issues. Overall, a root cause analysis provides a comprehensive framework for improving patient safety and quality of care.