Certified Professional in Patient Safety (CPPS) Practice Exam

When developing an action plan as part of a Root Cause Analysis (RCA), what type of action is most preferable to prevent recurrence?

1. Create programs to instruct staff on proper technique in the involved process.

2. Develop checklists for staff to avoid missing steps.

3. Add alerts in the Electronic Health Record to guide decisions.

4. Redesign the workflow to eliminate the steps that fail.

The correct answer is: Redesign the workflow to eliminate the steps that fail.

The most preferable action to prevent recurrence in a Root Cause Analysis (RCA) is to redesign the workflow to eliminate the steps that fail. This approach directly addresses the root causes of errors by modifying the process itself, rather than simply mitigating risks or providing guidance after the fact. By redesigning the workflow, the organization aims to create a more reliable system that inherently reduces the likelihood of error occurring. This can involve streamlining processes, removing unnecessary steps, or implementing fail-safes that prevent mistakes. Such fundamental changes can lead to a more sustainable solution that minimizes vulnerability to recurrence of the same issue. Other methods, while valuable, often serve as secondary measures that do not fundamentally alter the risk of errors. For instance, creating instructional programs and developing checklists may enhance staff performance and awareness but do not inherently change the underlying processes that led to the error. Adding alerts in the Electronic Health Record can improve decision-making but also focuses on response rather than proactive prevention. Overall, redesigning the workflow focuses on preventing the conditions that allow errors to occur in the first place, making it the most effective strategy for long-lasting safety improvements.