PSI Patient Safety 2 — Questions and Answers
Question 1: What is a medication error and how should it be managed in a pharmacy?
- Any preventable event that may cause or lead to inappropriate medication use or patient harm; it should be documented, reported, the patient assessed, and a root cause analysis conducted (Correct answer)
- An error only counts if the patient is harmed
- Medication errors should be hidden to protect the pharmacy's reputation
- Only dispensing the wrong drug counts as a medication error
Correct answer: Any preventable event that may cause or lead to inappropriate medication use or patient harm; it should be documented, reported, the patient assessed, and a root cause analysis conducted
Medication errors include any preventable event at any stage: prescribing, dispensing, administration, or monitoring. When discovered, the patient must be assessed for harm, the prescriber informed, an incident report completed, the error documented, and a root cause analysis conducted to prevent recurrence.
Question 2: What is the pharmacist's role in pharmacovigilance?
- To monitor the safety of medicines in everyday use, detect new or changing safety signals, report adverse events, and contribute to the ongoing assessment of medicine benefit-risk profiles (Correct answer)
- Pharmacovigilance is only the manufacturer's responsibility
- It only applies during clinical trials
- Pharmacists have no role in pharmacovigilance
Correct answer: To monitor the safety of medicines in everyday use, detect new or changing safety signals, report adverse events, and contribute to the ongoing assessment of medicine benefit-risk profiles
Pharmacovigilance (the science of monitoring drug safety) is a responsibility shared by all healthcare professionals. Pharmacists contribute by reporting ADRs to the HPRA, monitoring patients for drug safety issues, educating patients about potential adverse effects, and staying informed about drug safety alerts.
Question 3: What should a pharmacist do if they identify a drug recall notice?
- Immediately quarantine the affected stock, check dispensing records for patients who received the recalled product, notify affected patients and their prescribers, and arrange returns (Correct answer)
- Wait until the stock runs out
- Only act if a patient complains
- Continue dispensing the product until a replacement is available
Correct answer: Immediately quarantine the affected stock, check dispensing records for patients who received the recalled product, notify affected patients and their prescribers, and arrange returns
Upon receiving a drug recall notice from the HPRA, the pharmacist must immediately quarantine affected stock, check records to identify patients who received the product, contact those patients and their prescribers, arrange for returns to the supplier, and document all actions taken.
Question 4: What is the importance of medication reconciliation when a patient is discharged from hospital?
- To ensure continuity of care by comparing the discharge prescription with the patient's pre-admission medications, identifying any intentional changes, and preventing unintended omissions or duplications (Correct answer)
- Medication reconciliation is only needed on admission
- It is the hospital's sole responsibility
- The community pharmacist has no role in discharge reconciliation
Correct answer: To ensure continuity of care by comparing the discharge prescription with the patient's pre-admission medications, identifying any intentional changes, and preventing unintended omissions or duplications
Community pharmacists play a vital role in discharge reconciliation. They should compare the discharge prescription with the patient's previous medication record, identify any changes (new medicines, stopped medicines, dose changes), verify these changes were intentional, and counsel the patient on the updated regimen.
Question 5: What measures should a pharmacy implement to prevent dispensing errors?
- Separate LASA products, use barcode scanning, implement independent double-checking, maintain adequate staffing, reduce interruptions during dispensing, and report all near misses (Correct answer)
- Speed up dispensing to reduce waiting times
- Remove all safety checks to improve efficiency
- Only rely on the pharmacist's memory and experience
Correct answer: Separate LASA products, use barcode scanning, implement independent double-checking, maintain adequate staffing, reduce interruptions during dispensing, and report all near misses
Error prevention requires multiple strategies: physical separation of similar products, barcode verification technology, mandatory independent final checks, appropriate staffing levels, a quiet dispensing environment, standard operating procedures, near-miss reporting, and a positive safety culture.
Question 6: What is the pharmacist's responsibility regarding cold chain management for medicines requiring refrigeration?
- To maintain the cold chain (2-8°C) throughout storage and supply, monitor and record temperatures daily, investigate any breaches, and not supply medicines that have been compromised (Correct answer)
- Only the wholesaler is responsible for cold chain
- Temperature monitoring is optional
- Medicines can be returned to the fridge after being left out overnight
Correct answer: To maintain the cold chain (2-8°C) throughout storage and supply, monitor and record temperatures daily, investigate any breaches, and not supply medicines that have been compromised
Cold chain management ensures temperature-sensitive medicines (vaccines, insulin, biologics) remain within 2-8°C from receipt to supply. Daily temperature monitoring, calibrated equipment, breach protocols, and patient counselling on home storage are all pharmacist responsibilities.
PSI Patient Safety 2
What is a medication error and how should it be managed in a pharmacy?