Patient Safety & Clinical Pharmacy Flashcards

What is the 'five rights' framework in medication safety?

Answer: Right patient, right drug, right dose, right route, right time

The five rights are a widely used medication safety framework: right patient, right drug, right dose, right route, and right time — all must be confirmed to prevent medication errors.

Which drug interaction should be identified when a patient on ramipril is prescribed potassium supplementation?

Answer: Hyperkalaemia risk — ACE inhibitors reduce aldosterone, raising potassium levels

ACE inhibitors reduce angiotensin II-mediated aldosterone secretion, decreasing urinary potassium excretion. Adding potassium supplements increases hyperkalaemia risk, potentially causing dangerous arrhythmias.

A patient on warfarin starts a course of amiodarone. What monitoring is required?

Answer: Increased INR monitoring; warfarin dose likely needs to be reduced

Amiodarone inhibits CYP2C9, reducing warfarin metabolism and significantly increasing INR. Warfarin dose often needs to be halved. Enhanced INR monitoring is essential when starting amiodarone.

What is meant by 'polypharmacy' and when does it become a concern?

Answer: Use of multiple medicines; becomes a concern when it increases risk of interactions, side effects, and non-adherence

Polypharmacy (typically defined as ≥5 medicines) raises patient safety concerns due to increased drug interaction risk, adverse effects, pill burden, and adherence challenges, particularly in elderly patients.

Which score is used to assess bleeding risk in patients with atrial fibrillation being considered for anticoagulation?

Answer: HAS-BLED score

HAS-BLED estimates bleeding risk in AF patients on anticoagulation. It scores factors including Hypertension, Abnormal renal/liver function, Stroke history, Bleeding tendency, Labile INR, Elderly (>65), Drugs/alcohol.

What is the pharmacist's role in medicines reconciliation on hospital admission?

Answer: Accurately determine the patient's complete pre-admission medication list and reconcile it with hospital prescriptions

Medicines reconciliation at admission involves verifying what medicines the patient was actually taking (using GP records, patient history, pharmacy records) and ensuring the inpatient prescription accurately reflects this.