CPhT Medication Safety 3 — Questions and Answers
Question 1: Which system-level safety intervention physically prevents a wrong drug or dose from being selected?
- Independent double-check
- Forcing function (Correct answer)
- Fail-safe design
- Standardization
Correct answer: Forcing function
A forcing function creates a physical or system barrier that makes it impossible to proceed with an incorrect action (e.g., unique connectors for epidural vs. IV tubing).
Question 2: A technician accidentally fills a prescription with the 10 mg tablet instead of the 100 mg tablet. At what point in the dispensing process should this error ideally be caught?
- During product selection
- During pharmacist final verification (Correct answer)
- After patient counseling
- At the point of sale
Correct answer: During pharmacist final verification
The pharmacist's final verification is the last safety checkpoint before dispensing, designed to catch errors like incorrect strength selection.
Question 3: Which metric does ISMP use to categorize the severity of a medication error?
- Harm index scale 1–10
- NCC MERP index categories A–I (Correct answer)
- FDA MedWatch severity grades
- WHO adverse event scale
Correct answer: NCC MERP index categories A–I
ISMP uses the NCC MERP Index for Categorizing Medication Errors, which ranges from Category A (no error) through Category I (death).
Question 4: Why should leading zeros always be used but trailing zeros never used on medication labels?
- To comply with DEA regulations
- To prevent 10-fold dosing errors (Correct answer)
- To meet HIPAA standards
- To satisfy USP sterility requirements
Correct answer: To prevent 10-fold dosing errors
A trailing zero (e.g., 1.0 mg misread as 10 mg) and absence of a leading zero (e.g., .5 mg misread as 5 mg) can both cause 10-fold dosing errors.
Question 5: What is the primary purpose of a Failure Mode and Effects Analysis (FMEA) in pharmacy?
- Investigate errors after they occur
- Proactively identify where a process could fail before errors happen (Correct answer)
- Train staff on medication error categories
- Report adverse events to the FDA
Correct answer: Proactively identify where a process could fail before errors happen
FMEA is a prospective risk analysis tool that identifies potential failure points in a process before errors occur.
Question 6: A child receives an adult dose of acetaminophen due to a weight-based calculation error. Which pediatric safety guideline would have helped prevent this?
- Dispensing only unit-dose packaging
- Using mg/kg dosing with weight verification (Correct answer)
- Requiring a brand-name drug only
- Using tall man lettering
Correct answer: Using mg/kg dosing with weight verification
Pediatric dosing should always be calculated using mg/kg with verified patient weight to prevent under- or overdosing.
Question 7: Which action by a pharmacy technician constitutes a dispensing error of omission?
- Filling the wrong strength
- Failing to fill a required refill on time
- Providing a drug without a patient label
- Not including a required auxiliary label (Correct answer)
Correct answer: Not including a required auxiliary label
Omitting a required auxiliary label (e.g., 'Take with food' or 'May cause drowsiness') is a dispensing error of omission that can lead to patient harm.
CPhT Medication Safety 3
Which system-level safety intervention physically prevents a wrong drug or dose from being selected?