Certified Professional in Patient Safety (CPPS) Practice Exam

Which event provides the best opportunity for conducting a root cause analysis (RCA)?

1. A post-operative patient removes his own IV, causing a skin tear from the tape.

2. A patient with no known allergies experiences an anaphylactic reaction to an antibiotic.

3. The biopsy samples from a colonoscopy are never received by pathology after the procedure.

4. Depressed respirations related to sedation in the same department.

The correct answer is: The biopsy samples from a colonoscopy are never received by pathology after the procedure.

The correct answer identifies a scenario that involves a clear systemic failure that warrants a comprehensive investigation to understand underlying factors and processes. In the case of biopsy samples not being received by pathology after a procedure, this event indicates a breakdown in communication and workflow that could affect patient outcomes significantly. Such a situation not only impacts the current patient's care but could also pose risks for future patients, emphasizing the importance of understanding how such an error occurred to prevent reoccurrence. Root cause analysis is most effectively conducted on events where there is potential for serious harm or where processes fail, leading to adverse outcomes. The scenario concerning the biopsy samples highlights a specific and factual issue—a tangible failure in protocol that can be dissected and analyzed. The RCA aims to determine not just what went wrong, but why it went wrong, enabling the development of preventive strategies. Other events, while also serious, may not reflect systemic issues as clearly as the one concerning the biopsy samples. For example, the anaphylactic reaction to an antibiotic pertains to individual patient risk factors or potential gaps in allergy screening, which might not indicate a systematic flaw. Similarly, the other scenarios focus more on situational errors rather than widespread process failures that need to be addressed through an RCA. The case of the biopsy samples