CPPS flashcards
CPPS · Build recall with a focused review session.
32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Just culture
- A culture that distinguishes human error, at-risk behavior, and reckless behavior, responding with support, coaching, or discipline respectively, so that reporting and learning are encouraged.
- Psychological safety
- A shared team belief that it is safe to take interpersonal risks such as speaking up, asking questions, or admitting mistakes without fear of humiliation or punishment.
- Swiss cheese model
- Reason's model in which harm occurs when latent conditions and active failures align across defensive layers, like holes lining up in slices of cheese.
- High-alert medication
- A drug that carries a heightened risk of significant patient harm when used in error; examples include anticoagulants, insulin, opioids, and concentrated electrolytes.
- Donabedian framework
- A model that evaluates quality through structure (resources and organization), process (what is done), and outcome (results for patients); using all three avoids misleading conclusions.
- Global trigger tool
- A retrospective chart review method that uses triggers such as antidote administration or unplanned reoperation to estimate adverse event rates that voluntary reporting misses.
- Control chart
- A time-series plot with statistical limits used to distinguish common-cause variation from special-cause variation, helping teams know whether a change had a real effect.
- Root cause analysis
- A structured retrospective investigation of a serious adverse event that identifies system vulnerabilities and contributing factors, then produces a prioritized action plan rather than assigning individual blame.
- Failure mode and effects analysis
- A prospective method that identifies ways a process or device can fail, then scores each failure mode by severity, occurrence, and detectability to prioritize prevention.
- PDSA cycle
- Plan-Do-Study-Act: a small-scale iterative test of change in which predictions are compared with observed results before the change is adopted or spread.
- Five whys
- An iterative questioning technique that moves from a proximate cause to underlying system causes by repeatedly asking why, stopping when reaching an actionable cause.
- SBAR
- A structured communication tool standing for Situation, Background, Assessment, and Recommendation, used for handoffs and escalation of concerns.
- CUS
- A graded assertiveness tool standing for Concerned, Uncomfortable, and Safety issue, used to escalate a concern when a team member is not being heard.
- Closed-loop communication
- A communication pattern in which the sender transmits a message, the receiver repeats it back, and the sender confirms accuracy, reducing errors in high-tempo settings.
- Second victim
- A clinician involved in an adverse event who experiences guilt, shame, or distress; peer support and structured debriefing help recovery and future reporting.
- Open disclosure
- A structured conversation with a patient or family after harm covering what happened, its consequences, an expression of regret, the investigation plan, and follow-up contact.
- Speak-up culture
- An environment in which staff feel comfortable raising safety concerns and see that reports receive visible, non-punitive follow-up, encouraging future reporting.
- Safety huddle
- A short, recurring team meeting used to surface risks, share learning, and assign actions; standardization and frequency improve its reliability.
- Leadership walkround
- A structured, scheduled visit in which leaders ask frontline staff about safety concerns and follow up on identified issues; effectiveness depends on closed-loop feedback.
- Sentinel event
- An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, that requires immediate investigation and response.
- Patient identification rule
- Use at least two identifiers, such as name and date of birth or medical record number, before care, medication, blood, or specimens; never use room or bed.
- Time-out
- A team pause immediately before a procedure to confirm patient identity, procedure, site, consent, allergies, positioning, equipment, and anticipated critical events.
- Retained surgical items
- Surgical materials left in a patient after a procedure; prevention relies on standardized counts, radiopaque sponges, and resolving discrepancies before closure.
- WHO 5 Moments
- Hand hygiene indications: before touching a patient, before a clean or aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching surroundings.
- Teach-back
- A technique in which patients explain information in their own words to confirm understanding, improving comprehension and reducing errors at discharge or during education.
- Health literacy
- The degree to which individuals can obtain, process, and understand health information to make decisions; plain language and limited key points improve safety.
- Diagnostic error
- A failure to establish an accurate and timely explanation of a patient's health problem or to communicate that explanation to the patient.
- Alarm fatigue
- Desensitization caused by excessive alarms, leading staff to ignore or delay response; interventions include alarm rationalization and role-based notification.
- Forcing function
- A design feature that makes an error impossible or immediately visible, such as incompatible connectors or locked cabinets for high-alert drugs.
- High-reliability organizing
- Five principles: preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise.
- Morbidity and mortality conference
- A recurring clinical meeting that reviews adverse outcomes and deaths to identify system improvements and support professional learning.
- Regression to the mean
- The statistical tendency of extreme measurements to move toward the average on repeat measurement; improvement after an extreme value may not reflect the intervention.