ISMP Safe Medication I 3 — Questions and Answers
Question 1: A nurse is preparing an IV infusion and notices the vial label reads '0.9% Sodium Chloride' but the solution appears slightly cloudy. What is the correct ISMP-aligned action?
- Administer it quickly before the cloudiness worsens
- Discard the vial and obtain a new one, reporting the product to the pharmacy (Correct answer)
- Filter the solution through a 0.22-micron inline filter before infusing
- Warm the vial to room temperature and re-inspect after 10 minutes
Correct answer: Discard the vial and obtain a new one, reporting the product to the pharmacy
Any IV solution that appears abnormal must be discarded and reported; particulate matter or cloudiness may indicate contamination or degradation.
Question 2: Per ISMP high-alert medication principles, which of the following drugs appears on the ISMP list of high-alert medications in community/ambulatory settings?
- Acetaminophen 325 mg
- Warfarin (anticoagulant) (Correct answer)
- Amoxicillin 500 mg
- Omeprazole 20 mg
Correct answer: Warfarin (anticoagulant)
Warfarin is on the ISMP high-alert medication list for community settings because errors involving it can lead to serious bleeding or clotting events.
Question 3: Which error-prevention strategy does ISMP recommend to reduce confusion between metric units on prescriptions?
- Always write doses in grains or apothecary units for clarity
- Use only metric units (mg, mL, mcg) and avoid non-standard abbreviations and apothecary symbols (Correct answer)
- Allow prescribers to use any unit system they prefer to ensure prescriber autonomy
- Convert all doses to teaspoons for patient comprehension
Correct answer: Use only metric units (mg, mL, mcg) and avoid non-standard abbreviations and apothecary symbols
ISMP strongly advocates for metric-only dosing to eliminate conversion errors and ambiguity caused by outdated apothecary or household measurements.
Question 4: A 6-year-old weighing 20 kg is prescribed amoxicillin. The prescriber writes '500 mg three times daily.' The standard pediatric dose is 25–45 mg/kg/day. What is the safety concern?
- The dose is within the normal pediatric range and safe to dispense
- At 1500 mg/day for a 20 kg child, this exceeds 45 mg/kg/day and warrants pharmacist clarification (Correct answer)
- Amoxicillin has no pediatric dose ceiling and is always safe
- The prescriber should switch to an injectable formulation for children
Correct answer: At 1500 mg/day for a 20 kg child, this exceeds 45 mg/kg/day and warrants pharmacist clarification
Weight-based dose verification is essential in pediatrics; 1500 mg/day ÷ 20 kg = 75 mg/kg/day, well above the recommended ceiling.
Question 5: According to ISMP, which abbreviation should NEVER be used on medication orders because it has been misread and caused patient harm?
- mg (milligrams)
- U (for units) (Correct answer)
- mL (milliliters)
- mcg (micrograms)
Correct answer: U (for units)
ISMP's 'Do Not Use' list includes 'U' for units because it has been misread as '0' (zero), leading to tenfold overdoses.
Question 6: What is the primary purpose of an independent double-check for high-alert medications?
- To save time by having two nurses prepare the dose simultaneously
- To have a second clinician independently verify the drug, dose, route, and rate before administration (Correct answer)
- To ensure one nurse can delegate preparation to another without checking
- To reduce documentation burden by splitting the charting responsibility
Correct answer: To have a second clinician independently verify the drug, dose, route, and rate before administration
An independent double-check means the second clinician verifies without prompting from the first, ensuring a true safety redundancy and not just a co-signature.
Question 7: A pharmacist receives an order for 'Zantac 150 mg PO BID.' The drug was withdrawn from the US market. What is the appropriate response?
- Dispense ranitidine from existing stock to avoid delays
- Contact the prescriber to recommend a safe alternative such as famotidine or omeprazole (Correct answer)
- Substitute with any available H2 blocker without notifying the prescriber
- Inform the patient they must purchase an OTC version instead
Correct answer: Contact the prescriber to recommend a safe alternative such as famotidine or omeprazole
Ranitidine (Zantac) was recalled by the FDA due to NDMA contamination; the pharmacist must contact the prescriber to select a safe alternative.
ISMP Safe Medication I 3
A nurse is preparing an IV infusion and notices the vial label reads '0.9% Sodium Chloride' but the solution appears slightly cloudy.
What is the correct ISMP-aligned action?