CSPT Medication Safety 5 — Questions and Answers
Question 1: 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:
- Near miss
- Sentinel event requiring root cause analysis (Correct answer)
- Routine dispensing variation
- Documentation discrepancy
Correct 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.
Question 2: Which of the following practices BEST reduces the risk of high-alert medication errors in a CSP environment?
- Using abbreviations for quick labeling
- Applying auxiliary warning labels and requiring pharmacist verification before dispensing (Correct answer)
- Stocking high-alert drugs in easily accessible locations for speed
- Preparing high-alert drugs in larger batches to reduce handling frequency
Correct 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.
Question 3: 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?
- Override the alert if confident in the calculation
- Contact the prescriber and pharmacist immediately to verify the dose before proceeding (Correct answer)
- Prepare the dose as ordered since the system may be wrong
- Reduce the dose by half and note the adjustment on the label
Correct 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.
Question 4: Which labeling element is MOST critical for preventing medication errors with compounded electrolyte solutions?
- The compounder's initials
- The exact concentration expressed in mEq/mL or mmol/mL (Correct answer)
- The color of the container cap
- The lot number of the primary container closure
Correct 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.
Question 5: During a medication safety audit, a pharmacy identifies that 3 of 10 CSP labels omitted the route of administration. This finding most directly violates:
- USP <1> general notices on pharmaceutical compounding
- USP <797> and state board labeling requirements for compounded sterile preparations (Correct answer)
- OSHA hazard communication standards
- FDA guidance on drug product expiration dating
Correct answer: USP <797> and state board labeling requirements for compounded sterile preparations
USP <797> and state board regulations require that all CSP labels include the route of administration as a mandatory element.
Question 6: A compounding technician inadvertently touches the critical site of a needleless connector while preparing an IV admixture. The MOST appropriate action is to:
- Continue preparation since gloves were worn
- Discard the component and obtain a new one, then document the event (Correct answer)
- Clean the site with an alcohol swab and continue
- Complete preparation and add a note to the batch record
Correct 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.
Question 7: Which of the following is the BEST example of a system-level intervention to reduce medication errors in sterile compounding?
- Telling technicians to 'be more careful'
- Implementing barcode scanning verification of all drug vials before compounding (Correct answer)
- Posting a list of common errors in the break room
- Requiring technicians to sign an error acknowledgment form
Correct 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.
CSPT Medication Safety 5
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: