CFPN Medication Error Investigation and Patient Safety 1 — Questions and Answers
Question 1: According to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), which category represents an error that reached the patient and caused death?
- Category I (Correct answer)
- Category E
- Category G
- Category B
Correct answer: Category I
NCC MERP Category I represents errors that may have contributed to or resulted in patient death.
Question 2: What is a 'near miss' in medication safety terminology?
- An error that was caught and corrected before reaching the patient (Correct answer)
- A medication error that caused minor harm
- A prescribing error discovered after patient discharge
- An incorrect medication that was returned to the pharmacy
Correct answer: An error that was caught and corrected before reaching the patient
Near misses are caught errors that never reach the patient; they are valuable learning opportunities for system improvement.
Question 3: In forensic investigation of a fatal medication error, which principle guides the analysis toward system failures rather than individual blame?
- Just Culture philosophy (Correct answer)
- Zero tolerance policy
- Respondeat superior doctrine
- Res ipsa loquitur
Correct answer: Just Culture philosophy
Just Culture distinguishes between human error, at-risk behavior, and reckless behavior to promote learning and appropriate accountability.
Question 4: Which medication error is most commonly associated with look-alike/sound-alike (LASA) drug pairs?
- Wrong drug error (Correct answer)
- Wrong dose error
- Wrong route error
- Wrong patient error
Correct answer: Wrong drug error
LASA drug pairs cause wrong drug errors when staff confuse similar-looking or similar-sounding medication names.
Question 5: A root cause analysis (RCA) of a medication error is primarily conducted to:
- Identify systemic factors that contributed to the error and prevent recurrence (Correct answer)
- Determine legal liability for the error
- Discipline the individual who made the error
- Document the error for insurance purposes
Correct answer: Identify systemic factors that contributed to the error and prevent recurrence
RCAs focus on system-level contributing factors and corrective actions rather than assigning individual blame.
Question 6: Which of the following is an example of a high-alert medication requiring extra safety precautions due to significant harm potential?
- Concentrated electrolytes (e.g., concentrated potassium chloride) (Correct answer)
- Acetaminophen 325 mg tablets
- Artificial tears
- Oral multivitamins
Correct answer: Concentrated electrolytes (e.g., concentrated potassium chloride)
Concentrated electrolytes are on the ISMP high-alert medication list because errors can rapidly cause life-threatening arrhythmias.
CFPN Medication Error Investigation and Patient Safety 1
According to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), which category represents an error that reached the patient and caused death?