CFPN Medication Error Investigation and Patient Safety 2 — Questions and Answers
Question 1: When conducting a forensic review of a medication error, which medical record component provides the clearest timeline of medication administration?
- Medication Administration Record (MAR) (Correct answer)
- Physician progress notes
- Nursing narrative notes
- Pharmacy dispensing records alone
Correct answer: Medication Administration Record (MAR)
The MAR provides a time-stamped, systematic record of every medication administered, making it central to forensic timeline reconstruction.
Question 2: A patient receives 10 times the ordered dose of insulin due to a decimal point error. This is an example of which type of medication error?
- Wrong dose error (Correct answer)
- Wrong drug error
- Wrong patient error
- Wrong route error
Correct answer: Wrong dose error
Administering 10 times the ordered dose due to a decimal error is a wrong dose error regardless of other factors.
Question 3: Which agency requires hospitals to report sentinel events including serious medication errors?
- The Joint Commission (TJC) (Correct answer)
- The Department of Labor
- The Drug Enforcement Administration
- The Federal Trade Commission
Correct answer: The Joint Commission (TJC)
The Joint Commission requires accredited facilities to report sentinel events and conduct root cause analyses as part of its accreditation standards.
Question 4: In a forensic medication error investigation, what does 'failure mode and effects analysis' (FMEA) proactively identify?
- Potential failure points in a medication process before errors occur (Correct answer)
- The cause of a specific error that already happened
- Individual staff members responsible for an error
- Documentation gaps in the medical record
Correct answer: Potential failure points in a medication process before errors occur
FMEA is a prospective tool that systematically identifies where a process could fail and the potential consequences before harm occurs.
Question 5: A forensic pharmacy nurse discovers that a nurse administered a medication to the wrong patient because two patients had similar last names and were in adjacent rooms. Which system error contributed most?
- Failure to use two-patient identifiers before medication administration (Correct answer)
- Understaffing on the unit
- The pharmacy dispenser did not label clearly
- The medication was stored incorrectly
Correct answer: Failure to use two-patient identifiers before medication administration
The Joint Commission's National Patient Safety Goal requires two unique patient identifiers before medication administration to prevent wrong-patient errors.
Question 6: Which term describes the cognitive bias where a clinician anchors on an initial incorrect diagnosis or medication order, leading to subsequent errors?
- Anchoring bias (Correct answer)
- Confirmation bias
- Availability heuristic
- Framing effect
Correct answer: Anchoring bias
Anchoring bias occurs when initial information disproportionately influences subsequent decisions, even when new contradictory evidence emerges.
CFPN Medication Error Investigation and Patient Safety 2
When conducting a forensic review of a medication error, which medical record component provides the clearest timeline of medication administration?