Pharmacy Medication Safety and Error Prevention 2 — Questions and Answers
Question 1: Which system is commonly used to analyze the root cause of medication errors?
- HIPAA review panel
- Root Cause Analysis (RCA) (Correct answer)
- DEA Form 106 investigation
- FDA MedWatch report
Correct answer: Root Cause Analysis (RCA)
Root Cause Analysis (RCA) is a structured process used to identify the underlying system failures that contributed to a medication error, focusing on processes rather than individuals.
Question 2: An error-prone abbreviation that should NEVER be used on prescriptions according to ISMP/TJC is:
- mg (milligrams)
- U for units (Correct answer)
- mL (milliliters)
- PO (by mouth)
Correct answer: U for units
'U' for units is on The Joint Commission's Do Not Use list because it can be mistaken for '0' (zero) or '4', potentially causing 10-fold dosing errors.
Question 3: Independent double-checks are most valuable for which type of medications?
- All OTC products
- High-alert medications such as insulin, heparin, and chemotherapy (Correct answer)
- Vitamins and supplements
- Antacids and laxatives
Correct answer: High-alert medications such as insulin, heparin, and chemotherapy
Independent double-checks — where a second qualified person verifies the drug, dose, and patient — are a critical safety layer for high-alert medications with narrow margins and serious harm potential.
Question 4: MedWatch is the FDA's voluntary reporting program for:
- Reporting Medicaid fraud
- Reporting serious adverse events and medication errors (Correct answer)
- Tracking narcotic prescription refills
- Monitoring pharmacy technician license status
Correct answer: Reporting serious adverse events and medication errors
FDA MedWatch (Safety Reporting Portal) allows healthcare professionals and consumers to voluntarily report serious adverse events, medication errors, and product quality problems.
Question 5: Which practice best reduces dispensing errors caused by distractions?
- Answering phones while verifying prescriptions
- Designating quiet no-interruption zones during verification (Correct answer)
- Processing multiple prescriptions simultaneously
- Relying on memory rather than written checklists
Correct answer: Designating quiet no-interruption zones during verification
Designating a no-interruption zone (NIZ) during prescription verification is an evidence-based safety practice that reduces distraction-related dispensing errors.
Question 6: A patient returns a medication claiming it makes them feel dizzy. After reviewing, the pharmacy realizes a 100 mg tablet was dispensed instead of 10 mg. This is an example of a:
- Adverse drug reaction
- Medication error — wrong strength dispensed (Correct answer)
- Known side effect of the medication
- Contraindication error
Correct answer: Medication error — wrong strength dispensed
Dispensing the wrong strength (100 mg instead of 10 mg) constitutes a medication error — specifically a dosing error — that resulted in a preventable adverse outcome.
Pharmacy Medication Safety and Error Prevention 2
Which system is commonly used to analyze the root cause of medication errors?