ISMP Medication Error Prevention 2 — Questions and Answers
Question 1: ISMP's 'error-prone abbreviations' list includes which abbreviation that should never be used in medication orders?
- PO
- IV
- QD (for every day) (Correct answer)
- BID
Correct answer: QD (for every day)
QD is on ISMP's error-prone abbreviations list because it can be misread as QID (four times daily), potentially causing a fourfold overdose.
Question 2: According to ISMP, a 'near miss' in medication safety is best defined as:
- An error that causes severe patient harm
- An error that was caught before reaching the patient (Correct answer)
- A medication shortage
- An outdated prescription
Correct answer: An error that was caught before reaching the patient
A near miss is an error that was intercepted before it reached the patient, providing a critical learning opportunity to prevent future harm.
Question 3: Which decade-long effort by ISMP contributed most to eliminating the use of leading zeros in drug doses (e.g., .5 mg should be written as 0.5 mg)?
- Error-prone abbreviations campaign (Correct answer)
- High-alert medication campaign
- Safe medication practices guidelines
- Smart pump implementation
Correct answer: Error-prone abbreviations campaign
ISMP's error-prone abbreviations campaign specifically targets writing practices like missing leading zeros that cause tenfold dosing errors.
Question 4: ISMP recommends that pharmacies implement barcode medication verification primarily to:
- Speed up billing
- Verify the correct drug, dose, and patient at the point of dispensing (Correct answer)
- Track inventory only
- Replace pharmacist review
Correct answer: Verify the correct drug, dose, and patient at the point of dispensing
Barcode verification at dispensing and administration ensures the right drug, dose, and patient match, catching errors before administration.
Question 5: In medication error prevention, 'human factors engineering' refers to:
- Hiring more staff
- Designing equipment and environments to minimize human error (Correct answer)
- Training nurses harder
- Increasing manager oversight
Correct answer: Designing equipment and environments to minimize human error
Human factors engineering applies knowledge of human limitations and behaviors to design safer medical devices, software, and workflows.
Question 6: ISMP recommends that 'tall man lettering' be applied to drug names primarily on:
- Patient wristbands
- Drug labels, pharmacy systems, and medication administration records (Correct answer)
- Parking signs in hospitals
- Insurance claim forms
Correct answer: Drug labels, pharmacy systems, and medication administration records
Tall man lettering should appear on drug labels, pharmacy dispensing systems, and MAR to alert all users to look-alike/sound-alike confusion risks.
ISMP Medication Error Prevention 2
ISMP's 'error-prone abbreviations' list includes which abbreviation that should never be used in medication orders?