Pharmacy Medication Safety and Error Prevention 1 — Questions and Answers
Question 1: Which organization maintains the ISMP (Institute for Safe Medication Practices) High-Alert Medications list?
- FDA
- DEA
- ISMP (Correct answer)
- CMS
Correct answer: ISMP
ISMP (Institute for Safe Medication Practices) maintains the High-Alert Medications list — drugs that bear a heightened risk of causing significant patient harm when used in error.
Question 2: LASA (Look-Alike/Sound-Alike) medications should be stored in a pharmacy by:
- Alphabetical order regardless of risk
- Separating them physically and using tall-man lettering to distinguish names (Correct answer)
- Placing them next to each other for easy comparison
- Keeping them in a locked controlled substance cabinet
Correct answer: Separating them physically and using tall-man lettering to distinguish names
Separating LASA drugs on shelves and using tall-man lettering (e.g., hydrALAZINE vs. hydrOXYzine) are standard strategies to reduce confusion and dispensing errors.
Question 3: The '5 Rights' of medication administration include all of the following EXCEPT:
- Right patient
- Right drug
- Right pharmacist (Correct answer)
- Right dose
Correct answer: Right pharmacist
The 5 Rights are: right patient, right drug, right dose, right route, and right time. 'Right pharmacist' is not one of them.
Question 4: A medication error involving a wrong drug that was dispensed but caught before the patient received it is classified as a:
- Near miss (close call) (Correct answer)
- Adverse drug event
- Sentinel event
- Never event
Correct answer: Near miss (close call)
A near miss (close call) is an error that was caught and corrected before reaching the patient, unlike an adverse drug event where the patient is actually harmed.
Question 5: Concentrated electrolyte solutions (e.g., potassium chloride for injection) are considered high-alert because:
- They are controlled substances
- If given undiluted IV, they can cause fatal cardiac arrhythmias (Correct answer)
- They require refrigeration
- They have a very bitter taste that patients dislike
Correct answer: If given undiluted IV, they can cause fatal cardiac arrhythmias
Concentrated KCl injected undiluted IV can cause fatal hyperkalemia and cardiac arrest. Many facilities store them only in the pharmacy and never on patient care floors.
Question 6: Tall-man lettering is a strategy used to:
- Make drug labels easier to read for visually impaired patients
- Differentiate LASA drug names by capitalizing distinguishing letters (Correct answer)
- Indicate the drug is a controlled substance
- Show the drug requires refrigeration
Correct answer: Differentiate LASA drug names by capitalizing distinguishing letters
Tall-man lettering uses capital letters for the differentiating portion of similar drug names (e.g., DOBUTamine vs. DOPamine) to reduce LASA errors.
Pharmacy Medication Safety and Error Prevention 1
Which organization maintains the ISMP (Institute for Safe Medication Practices) High-Alert Medications list?