MTM Medication Safety & Error Prevention 3 — Questions and Answers
Question 1: A pharmacist performing MTM discovers a patient takes methotrexate daily instead of weekly for rheumatoid arthritis. This type of error is classified as:
- Wrong drug error
- Wrong dose frequency error (Correct answer)
- Omission error
- Transcription error
Correct answer: Wrong dose frequency error
Methotrexate for RA is dosed weekly; daily administration constitutes a wrong-frequency (schedule) error and can cause fatal toxicity.
Question 2: Which element of the Institute for Safe Medication Practices' 'Key Elements of the Medication Use System' is addressed by requiring pharmacist counseling at dispensing?
- Patient information (Correct answer)
- Drug information
- Communication of drug orders
- Labeling, packaging, and nomenclature
Correct answer: Patient information
Patient information encompasses ensuring the patient understands their medications, which pharmacist counseling directly addresses.
Question 3: A nurse administers IV potassium chloride undiluted as a bolus due to a missing 'MUST DILUTE' auxiliary label. Which contributing factor category does the missing label represent?
- Human performance limitation
- Labeling and packaging failure (Correct answer)
- Workplace distraction
- Lack of standardization
Correct answer: Labeling and packaging failure
Absent or inadequate auxiliary labels are a labeling and packaging failure that is a recognized contributing factor to high-alert medication errors.
Question 4: In the context of medication reconciliation, which transition of care has the highest risk for unintentional medication discrepancies?
- Annual wellness visit to specialist referral
- Hospital admission from the emergency department
- Discharge from hospital to skilled nursing facility (Correct answer)
- Telephonic MTM enrollment
Correct answer: Discharge from hospital to skilled nursing facility
Hospital discharge to skilled nursing facilities is a high-risk transition because multiple care teams hand off simultaneously and medication lists are frequently incomplete or discordant.
Question 5: According to the FDA MedWatch program, which of the following is a mandatory reporter of serious adverse drug events?
- Community pharmacist
- Patients and caregivers
- Drug manufacturers (Correct answer)
- MTM-certified pharmacists only
Correct answer: Drug manufacturers
Drug manufacturers are legally required (mandatory) to report serious adverse events to FDA via MedWatch; health professionals and patients report voluntarily.
Question 6: A look-alike packaging mix-up between metFORMIN and metroNIDAZOLE is BEST prevented by which system-level intervention?
- Educating patients about drug spelling
- Separating the two drugs in storage by at least two shelf spaces (Correct answer)
- Asking patients to verify the label at pickup
- Storing products in alphabetical order together
Correct answer: Separating the two drugs in storage by at least two shelf spaces
Physical separation of look-alike medications in storage is a proven system-level strategy to prevent inadvertent selection of the wrong product.
Question 7: An MTM pharmacist recommends that a patient's insulin pen needles be changed with each injection. The primary safety rationale is:
- Preventing lipodystrophy and inaccurate dosing from blunted needles (Correct answer)
- Reducing risk of allergic reaction to metal residue
- Ensuring sterility to prevent systemic infection
- Complying with OSHA sharps disposal regulations
Correct answer: Preventing lipodystrophy and inaccurate dosing from blunted needles
Reusing insulin needles causes needle tip barbing, which damages subcutaneous tissue, promotes lipodystrophy, and results in inconsistent insulin absorption.
MTM Medication Safety & Error Prevention 3
A pharmacist performing MTM discovers a patient takes methotrexate daily instead of weekly for rheumatoid arthritis.
This type of error is classified as: