ISMP Medication Administration Safety 2 — Questions and Answers
Question 1: ISMP identifies 'free-flow' of IV fluids as a significant risk. Which device feature is the most important safeguard against free-flow errors?
- Alarm-only infusion pumps
- Anti-free-flow (AFF) IV administration sets (Correct answer)
- Clear IV tubing for visual inspection
- Roller clamps on all IV lines
Correct answer: Anti-free-flow (AFF) IV administration sets
Anti-free-flow administration sets automatically close the tubing when removed from the pump, preventing uncontrolled gravity-driven infusion of medications.
Question 2: According to ISMP guidelines, what is the greatest risk associated with misconnection of enteral feeding tubing to an IV access site?
- Skin irritation at the IV site
- Introduction of enteral formula directly into the bloodstream (Correct answer)
- Blockage of the enteral feeding tube
- Inaccurate fluid intake measurement
Correct answer: Introduction of enteral formula directly into the bloodstream
Enteral-to-IV misconnections can cause fatal embolism or sepsis when enteral formula or medications are injected intravenously; ISMP recommends ENFit connectors to prevent this.
Question 3: ISMP recommends weight-based dosing for pediatric patients be calculated using which weight measurement?
- Estimated weight from age-based charts
- Actual current body weight measured at admission (Correct answer)
- Ideal body weight from growth charts
- Weight reported by parents upon arrival
Correct answer: Actual current body weight measured at admission
ISMP recommends using the patient's actual current body weight, measured and documented in kilograms at the time of admission, to prevent dosing errors in pediatric patients.
Question 4: Which abbreviation has ISMP placed on its 'Do Not Use' list because it has been misinterpreted as a number?
- mg (milligrams)
- U (units) (Correct answer)
- tab (tablet)
- cap (capsule)
Correct answer: U (units)
The abbreviation 'U' for units has been misread as '0', '4', or '6', leading to 10-fold or other dosing errors; ISMP recommends writing out 'units' in full.
Question 5: ISMP recommends that medications removed from automated dispensing cabinets (ADCs) using the 'override' function should be:
- Used routinely to improve workflow efficiency
- Limited to true emergencies and reviewed retrospectively by pharmacy (Correct answer)
- Permitted for any medication listed in the cabinet
- Documented only if an error occurs
Correct answer: Limited to true emergencies and reviewed retrospectively by pharmacy
Override retrieval bypasses pharmacist review, so ISMP recommends restricting it to genuine emergencies and mandating retrospective pharmacy review to identify potential errors.
Question 6: When preparing medications outside of pharmacy (i.e., at the bedside or in a procedure area), ISMP recommends that labels be applied:
- Only if the medication will be stored for later use
- Immediately after preparation, before the syringe is set down (Correct answer)
- After the medication is administered and documented
- Only for high-alert medications
Correct answer: Immediately after preparation, before the syringe is set down
ISMP requires immediate labeling of all prepared medications to prevent mix-ups, as an unlabeled syringe can be mistaken for another drug or dose within seconds.
Question 7: ISMP recommends that which of the following verbal/telephone orders be read back to the prescriber before administration?
- Only orders for controlled substances
- All verbal and telephone medication orders (Correct answer)
- Orders given during emergencies only
- Orders for high-alert medications only
Correct answer: All verbal and telephone medication orders
ISMP recommends a full read-back for all verbal and telephone orders to verify accuracy, as mishearing drug names, doses, or routes is common during oral communication.
ISMP Medication Administration Safety 2
ISMP identifies 'free-flow' of IV fluids as a significant risk.
Which device feature is the most important safeguard against free-flow errors?