CHSP Incident Investigation and Analysis Questions and Answers

Question 1

An incident investigation team is applying James Reason's "Swiss Cheese Model" of accident causation to analyze a medication error. In this model, what do the "holes" in the slices of cheese represent?

Accepted Answer

Latent failures or weaknesses in the organization's layers of defense.

Answer

In the Swiss Cheese Model, the slices of cheese are the organization's defenses and safeguards (e.g., policies, technologies, training). The holes represent latent conditions or hidden weaknesses within those defenses. An accident occurs when the holes in multiple defensive layers momentarily align, allowing a hazard to result in patient harm.

Question 2

A safety officer is interviewing a nurse immediately following a patient fall. To ensure an effective and unbiased investigation that supports a Just Culture, which interview approach is MOST appropriate?

Accepted Answer

Asking open-ended, non-leading questions such as, "Can you walk me through what happened from your perspective?"

Answer

Open-ended, non-leading questions encourage a narrative account of the event without assigning premature blame. This approach is crucial for uncovering system factors and latent conditions. Asking a direct "why" question can sound accusatory, having a manager present can be intimidating and stifle open communication, and focusing only on individual actions ignores the broader system context.

Question 3

Which of the following is the most significant benefit of systematically investigating and analyzing 'near miss' events in a healthcare setting?

Accepted Answer

It identifies and corrects system vulnerabilities before they cause patient harm.

Answer

The primary value of near miss analysis is its proactive nature. By investigating events where harm could have occurred but didn't, an organization can identify and fix latent system problems. This prevents similar circumstances from leading to an actual adverse event in the future. It is a cornerstone of a mature safety program.

Question 4

According to The Joint Commission, an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof, is known as a:

Accepted Answer

Sentinel Event

Answer

The Joint Commission specifically defines a 'Sentinel Event' as a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are so named because they signal the need for immediate investigation and response to identify and address the root causes and prevent recurrence.

Question 5

A root cause analysis team is investigating a wrong-site surgery. They are brainstorming all conceivable factors and grouping them into categories such as People, Process, Equipment, and Environment. Which classic analysis tool are they MOST likely using?

Accepted Answer

Fishbone (Ishikawa) Diagram

Answer

The Fishbone or Ishikawa diagram is a visual tool used to explore and categorize the potential causes of a problem. It is structured with the problem (or effect) at the 'head' of the fish, and the major categories of causes (like People, Process, Equipment) as the 'bones,' allowing the team to brainstorm and organize contributing factors.

CHSP - Certified Healthcare Safety Professional Practice Test

CHSP - Certified Healthcare Safety Professional Practice Test

CHSP Incident Investigation and Analysis Questions and Answers