Patient Safety: IHI CPPS Teamwork and
Communication | Questions 2024/25 Update All with
100% Correct Verified Answers
Linda, a pharmacist at an outpatient pharmacy for a medium-sized medical group, receives a
call from John, a nurse practitioner in the cardiology clinic. John tells Linda he needs to call in a
new prescription for hydrochlorothiazide at 50 mg once a day for Ms. Krane. At the end of the
conversation Linda says to John, "Okay, so you want Ms. Joanne Krane to have a new
prescription for hydrochlorothiazide at 50 mg by mouth once a day. Thirty pills and six refills."
What has Linda just done?
(A) Increased the likelihood of error by repeating an order
(B) Provided a read back
(C) Used SBAR in communication
(D) B and C - ✔✔B - This is a read back, which is used to confirm receipt of information (SBAR
is a system for delivering information). The pharmacist went through the step of verbally
verifying the order from the nurse practitioner by repeating it back to him, which can catch
mistakes. The additional time that a read back requires is not a waste. In fact, it may make work
more efficient by decreasing the need for later calls for clarification.
Use the following scenario to answer questions 8-9:
You are a member of an intensive care unit team in a regional hospital. This morning, a patient
had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin
derivative. There was a significant delay in getting the physician involved and beginning
treatment for this life-threatening condition. Fortunately, the patient is now stable and does
not seem to be experiencing any lasting effects.
, At this point, what would an effective team leader do?
(A) Report this adverse event in the anonymous reporting system so that it can be investigated
(B) Ask administrators to launch an investigation immediately to find out who was responsible
for this adverse event
(C) Apply the two-challenge rule.
(D) Conduct a debriefing - ✔✔D - Debriefings occur after events to find out what happened
and what could be done better next time. The most effective debriefings happen soon after the
event, while memories are fresh. However, the first priority is the patient's health - so
debriefings should only occur after the patient is stabilized.
The unit leaders are trying to figure out what changes they should make to prevent this
treatment delay from happening again. Given what you know about the incident, what change
would you recommend?
(A) Implement mandatory debriefings after the team works together on a patient.
(B) Fire the physician who failed to respond in a timely way.
(C) Stop using nursing assistants in the ICU.
(D) Implement the use of critical language in the ICU. - ✔✔D - Critical language (such as "I
need some clarity") is an agreed-upon phrase or set of words that indicates to all members of a
patient care team that there is a problem. It helps individuals who need to call attention to a
problem but don't know what to say, especially if the patient is awake and listening; and it also
serves as a red flag to team members that they need to stop and pay attention. Critical
language might have helped the nursing assistant speak up more quickly when he observed
problems with the patient's breathing. Debriefings, which occur after the event, would be a
valuable source of learning, but they would not be sufficient to prevent an event like this one in
the future.
Effective team leaders:
(A) Have multiple degrees.
(B) Are usually physicians.
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