ISMP Safe Medication I 5 — Questions and Answers
Question 1: A home health nurse finds a patient storing multiple medications in unlabeled containers 'to save space.' What is the primary safety risk per ISMP guidelines?
- Increased pill oxidation from improper container seals
- Risk of taking the wrong medication due to loss of identifying label information (Correct answer)
- Regulatory violation that must be reported to the state board of pharmacy
- No safety risk if the patient has been on the same medications for years
Correct answer: Risk of taking the wrong medication due to loss of identifying label information
Removing labels eliminates critical information such as drug name, dose, and expiration date, creating significant risk of medication mix-up and error.
Question 2: Which practice does ISMP identify as a root cause of errors related to oral liquid dosing in pediatric patients at home?
- Using oral syringes for measuring liquid medications
- Using household teaspoons, which are inaccurate and variable in volume (Correct answer)
- Refrigerating liquid antibiotics per pharmacist instructions
- Requesting weight-based dosing guidance from the pharmacist
Correct answer: Using household teaspoons, which are inaccurate and variable in volume
Household teaspoons vary significantly in actual volume (2–10 mL), making them unreliable for medication dosing; oral syringes or dosing cups should be used instead.
Question 3: During a medication administration, a nurse scans the patient's armband and receives an alert that the medication is not due for another 2 hours. According to ISMP bar-code medication administration (BCMA) principles, what should the nurse do?
- Override the alert and administer on time since the order is valid
- Assess the clinical reason for the alert, consult the prescriber if appropriate, and document the decision (Correct answer)
- Remove the patient's armband and re-scan to clear the error
- Administer the medication and report the scanner malfunction to IT
Correct answer: Assess the clinical reason for the alert, consult the prescriber if appropriate, and document the decision
Alerts from BCMA systems should not be routinely overridden; each alert requires clinical assessment and documentation to maintain the safety benefit of the system.
Question 4: An order is written for 'Celebrex (celecoxib) 200 mg PO daily.' A nurse unfamiliar with the drug confuses it with 'Cerebyx (fosphenytoin).' What ISMP strategy would most directly prevent this error?
- Training nurses to memorize all drug name pairs
- Using the generic name in the order alongside the brand name to reduce reliance on brand-name recognition alone (Correct answer)
- Requiring nurses to look up every drug before administration regardless of familiarity
- Storing Celebrex and Cerebyx in the same ADC drawer for convenience
Correct answer: Using the generic name in the order alongside the brand name to reduce reliance on brand-name recognition alone
ISMP recommends including the generic name on all orders so clinicians are not solely reliant on brand names that may be confused with similar-sounding products.
Question 5: A patient with renal impairment (CrCl 20 mL/min) is ordered the standard adult dose of a renally cleared antibiotic. What is the medication safety principle being violated?
- Renal impairment does not affect antibiotic dosing
- Failure to adjust dose for organ function, which can cause drug accumulation and toxicity (Correct answer)
- Antibiotics should never be used in patients with renal impairment
- Renal dose adjustments are only required for chemotherapy agents
Correct answer: Failure to adjust dose for organ function, which can cause drug accumulation and toxicity
Many drugs require dose reduction or interval extension in renal impairment to prevent toxic accumulation; this is a standard component of safe prescribing.
Question 6: Which action best reflects ISMP's principle of a 'just culture' following a medication error?
- Immediately suspending the nurse who made the error pending investigation
- Analyzing system factors contributing to the error and holding individuals accountable only for reckless behavior (Correct answer)
- Keeping the error confidential to protect the nurse's professional reputation
- Requiring the nurse to submit a written apology to the patient
Correct answer: Analyzing system factors contributing to the error and holding individuals accountable only for reckless behavior
Just culture distinguishes between system failures and individual recklessness, encouraging reporting and system improvement while maintaining appropriate accountability.
Question 7: A prescriber orders 'MgSO4 2 g IV over 20 minutes.' The nurse accidentally programs the pump for 2 g over 2 minutes. What preventive control does ISMP recommend for this scenario?
- Requiring nurses to administer MgSO4 only by gravity drip
- Programming MgSO4 into the smart pump drug library with hard limits on infusion rate (Correct answer)
- Limiting MgSO4 use to ICU settings exclusively
- Having the pharmacist physically present during all magnesium infusions
Correct answer: Programming MgSO4 into the smart pump drug library with hard limits on infusion rate
A smart pump drug library with hard rate limits would reject a 2-minute programming entry for MgSO4, catching the pump programming error before infusion begins.
ISMP Safe Medication I 5
A home health nurse finds a patient storing multiple medications in unlabeled containers 'to save space.' What is the primary safety risk per ISMP guidelines?