Medication Safety Flashcards

A patient receives a TPN bag that was intended for a different patient. The bag contained a different potassium concentration. This event is classified as a:

Answer: Sentinel event requiring root cause analysis

A wrong-patient medication error involving an electrolyte like potassium (which can cause fatal arrhythmias) qualifies as a sentinel event requiring root cause analysis.

Which of the following practices BEST reduces the risk of high-alert medication errors in a CSP environment?

Answer: Applying auxiliary warning labels and requiring pharmacist verification before dispensing

Auxiliary warning labels combined with mandatory pharmacist verification before dispensing are the strongest risk-reduction practices for high-alert medications.

A pharmacy technician notices that the IV workflow software flagged a dose as '5× the normal range' for a pediatric patient. What is the appropriate response?

Answer: Contact the prescriber and pharmacist immediately to verify the dose before proceeding

A 5× overdose alert for a pediatric patient must be escalated to the pharmacist and prescriber immediately — technicians should never unilaterally override or adjust such alerts.

Which labeling element is MOST critical for preventing medication errors with compounded electrolyte solutions?

Answer: The exact concentration expressed in mEq/mL or mmol/mL

Expressing electrolyte concentrations precisely in mEq/mL or mmol/mL prevents dangerous dosing errors caused by ambiguous strength labeling.

During a medication safety audit, a pharmacy identifies that 3 of 10 CSP labels omitted the route of administration. This finding most directly violates:

Answer: USP and state board labeling requirements for compounded sterile preparations

USP and state board regulations require that all CSP labels include the route of administration as a mandatory element.

A compounding technician inadvertently touches the critical site of a needleless connector while preparing an IV admixture. The MOST appropriate action is to:

Answer: Discard the component and obtain a new one, then document the event

Touching a critical site — even with gloved hands — compromises sterility; the component must be discarded and a new one used.

Which of the following is the BEST example of a system-level intervention to reduce medication errors in sterile compounding?

Answer: Implementing barcode scanning verification of all drug vials before compounding

Barcode scanning verification is a system-level technology intervention that catches errors at the point of use, far more effective than behavioral reminders alone.