Mixed Deck — All ISMP Topics Flashcards

A pharmacist notices that two drugs with similar names — HYDROmorphone and morphine — are stored adjacent to each other in the ADC. The best ISMP-aligned corrective action is to:

Answer: Separate the drugs in storage and apply tall-man lettering to differentiate them on ADC screens

Physical separation combined with tall-man lettering targets both the storage and labeling hazards for LASA pairs simultaneously.

Submitting a MedWatch report may be done by all of the following EXCEPT:

Answer: In person

The FDA's MedWatch program provides several convenient methods for reporting adverse events, product quality problems, and medication errors. These standard methods include online submission, fax, phone, and mail. Reporting 'in person' is not a listed or standard option for submitting a MedWatch report.

Which type of error reporting does ISMP encourage healthcare facilities to adopt?

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.

Which best describes the ISMP concept of a 'near miss' in medication safety?

Answer: An error that was caught before it reached the patient, providing a learning opportunity

A near miss is an event that could have caused harm but was intercepted before reaching the patient; ISMP encourages reporting these for system improvement.

Which of the following abbreviations does ISMP include on its 'Do Not Use' list because it is frequently misinterpreted?

Answer: QD

ISMP lists 'QD' (once daily) as dangerous because it is frequently misread as 'QID' (four times daily), causing fourfold overdoses.

ISMP's safety culture recommendations include which approach to staffing and workload?

Answer: Ensure safe staffing ratios that allow adequate time for medication safety practices

ISMP recognizes that unsafe staffing ratios create time pressure that leads to shortcuts and errors, so adequate staffing is a safety culture prerequisite.

One of the most frequent errors in IV medicine administration is:

Answer: Administering the drug too quickly

Administering an IV drug too quickly, especially potent medications, is a frequent and dangerous error. Rapid infusion can lead to adverse effects such as hypotension, cardiac arrhythmias, or other systemic reactions because the body doesn't have adequate time to metabolize or distribute the drug appropriately. Adhering to correct infusion rates is crucial for patient safety and optimal drug efficacy.

ISMP has identified which setting as having a particularly high risk for medication reconciliation errors in the US?

Answer: Long-term care and skilled nursing facilities during transitions from hospital

Long-term care and skilled nursing facilities receiving patients from hospitals are high-risk for reconciliation errors due to communication gaps and complex medication regimens.

Per ISMP guidance, which action best prevents wrong-patient medication errors during administration?

Answer: Using two independent patient identifiers before administration

ISMP and The Joint Commission require two independent identifiers (e.g., name + date of birth) to be confirmed directly at the bedside before administration.

When a smart infusion pump's drug library is bypassed by a clinician using 'free-flow' programming, what key safety feature is defeated?

Answer: The hard and soft dose limits that prevent dangerous infusion rates are no longer enforced

Bypassing the drug library eliminates the dose-error reduction software (DERS), removing the guardrails that catch lethal programming mistakes.

ISMP recommends that which of the following verbal/telephone orders be read back to the prescriber before administration?

Answer: All verbal and telephone medication orders

ISMP recommends a full read-back for all verbal and telephone orders to verify accuracy, as mishearing drug names, doses, or routes is common during oral communication.

A patient is ordered 'metformin 500 mg twice daily.' The pharmacy dispenses metformin 1000 mg tablets with instructions to take half a tablet. What is the primary concern per ISMP guidelines?

Answer: Scored tablets may be split, but unscored tablets should not be split as dose accuracy cannot be ensured

ISMP cautions that only scored tablets are designed for splitting; unscored tablets may result in unequal doses and potential harm.

Which environmental factor does ISMP identify as contributing most to medication administration errors?

Answer: Interruptions and distractions during the medication preparation and administration process

Interruptions during medication preparation are among the most consistently identified contributors to administration errors in ISMP research.

ISMP recommends that medication orders include the clinical indication primarily to:

Answer: Help verify appropriateness and catch orders written for the wrong patient or condition

Knowing the indication allows pharmacists and nurses to recognize if a dose or drug is inconsistent with the documented clinical purpose, catching potential errors.

Which of the following is an ISMP-recommended practice to prevent wrong-route errors with oral liquid medications?

Answer: Use only oral/enteral syringes that cannot connect to IV tubing

ISMP recommends using oral/enteral-specific syringes with connectors incompatible with IV lines to prevent accidental intravenous injection of oral medications.

Which action best reflects ISMP's principle of a 'just culture' following a medication error?

Answer: Analyzing system factors contributing to the error and holding individuals accountable only for reckless behavior

Just culture distinguishes between system failures and individual recklessness, encouraging reporting and system improvement while maintaining appropriate accountability.

According to ISMP, a 'near miss' in medication safety is best defined as:

Answer: An error that was caught before reaching the patient

A near miss is an error that was intercepted before it reached the patient, providing a critical learning opportunity to prevent future harm.

An order reads 'insulin regular 10 units sub-Q AC breakfast.' The nurse prepares the dose 45 minutes before the meal tray arrives. What error is most likely to occur?

Answer: Hypoglycemia if the meal is further delayed or the patient refuses to eat

Regular insulin given before a meal that is then delayed puts the patient at risk for hypoglycemia, a serious and preventable adverse event.

According to ISMP, a learning culture is likely the easiest to implement but the most difficult to sustain in the healthcare industry.

Answer: True

A learning culture, while easy to initiate with new policies, requires continuous effort, adaptation, and a shift in mindset to truly embed within an organization. Sustaining this culture in the complex and often high-pressure healthcare environment is challenging due to factors like resistance to change, resource limitations, and the need for ongoing education and reinforcement. Therefore, maintaining it long-term proves more difficult than its initial implementation.

According to ISMP, an effective error reporting system should be:

Answer: Voluntary, non-punitive, easy to use, and provide feedback to reporters

ISMP recommends error reporting systems that are easy to use, non-punitive, and provide feedback to reporters so that staff trust the process and participate consistently.