ISMP Medication Error Prevention 1 — Questions and Answers
Question 1: According to ISMP, what is the most effective strategy for preventing medication errors at the system level?
- Blaming individual nurses for errors
- Designing systems that make errors difficult to commit (Correct answer)
- Increasing staff punishments for mistakes
- Reducing pharmacist oversight
Correct answer: Designing systems that make errors difficult to commit
ISMP advocates for system-level redesign that makes errors hard to commit, recognizing that most errors result from system failures rather than individual negligence.
Question 2: ISMP's root cause analysis (RCA) approach to medication errors focuses on:
- Identifying the staff member to discipline
- Finding underlying system and process failures (Correct answer)
- Closing the pharmacy involved
- Reporting to law enforcement
Correct answer: Finding underlying system and process failures
RCA examines the root causes of errors by identifying systemic and process failures rather than placing blame on individuals.
Question 3: Which type of error reporting does ISMP encourage healthcare facilities to adopt?
- Mandatory punitive reporting only
- Voluntary, non-punitive near-miss and error reporting (Correct answer)
- Anonymous reporting to the media
- Reporting only fatal errors
Correct answer: Voluntary, non-punitive near-miss and error reporting
ISMP advocates for voluntary, non-punitive reporting systems so that near misses and errors are reported without fear, enabling learning and prevention.
Question 4: Forcing functions in medication safety are design features that:
- Allow workarounds to safety checks
- Make it impossible or very difficult to perform an unsafe action (Correct answer)
- Speed up medication administration
- Remove the need for double-checks
Correct answer: Make it impossible or very difficult to perform an unsafe action
Forcing functions are physical or system constraints that prevent errors from occurring, such as IV tubing that cannot be connected to an enteral port.
Question 5: ISMP recommends that medication orders be written using metric units and avoid which abbreviation that commonly causes errors?
- mg
- mL
- U for units (Correct answer)
- kg
Correct answer: U for units
The abbreviation 'U' for units is on ISMP's error-prone abbreviations list because it can be misread as a zero, turning 4U into 40 units.
Question 6: Which communication strategy does ISMP recommend to prevent transcription errors when receiving verbal medication orders?
- Write down the order immediately without repeating
- Read back and verify the order with the prescriber (Correct answer)
- Accept all verbal orders without question
- Record the call for later review
Correct answer: Read back and verify the order with the prescriber
ISMP recommends a read-back process where the receiver repeats the verbal order to the prescriber for confirmation before acting on it.
ISMP Medication Error Prevention 1
According to ISMP, what is the most effective strategy for preventing medication errors at the system level?