MTM Medication Safety & Error Prevention 5 — Questions and Answers
Question 1: Which of the following is the MOST effective system-level intervention to reduce medication errors compared to individual-level interventions?
- Counseling individual nurses about the dangers of medication errors
- Implementing computerized prescriber order entry (CPOE) with clinical decision support (Correct answer)
- Providing annual error-prevention training to pharmacy staff
- Posting ISMP error alerts in the break room
Correct answer: Implementing computerized prescriber order entry (CPOE) with clinical decision support
CPOE with clinical decision support intercepts errors at the point of prescribing through automated alerts, a system-level control that is far more reliable than education alone.
Question 2: An MTM pharmacist is reviewing a patient's medication list and finds that the patient is taking both sertraline and tramadol. The primary safety concern is:
- Increased risk of serotonin syndrome (Correct answer)
- Reduced tramadol efficacy due to CYP3A4 induction
- Additive anticholinergic burden
- Risk of hypertensive crisis
Correct answer: Increased risk of serotonin syndrome
Both sertraline (serotonergic agent) and tramadol (weak serotonin reuptake inhibitor and mu-opioid agonist) increase serotonergic activity, raising the risk of serotonin syndrome.
Question 3: When evaluating medication errors using root cause analysis (RCA), what is the goal of identifying 'root causes' rather than individual blame?
- To protect healthcare providers from legal liability
- To identify systemic failures and implement corrective system changes (Correct answer)
- To comply with state licensing board requirements
- To document errors for future staff performance reviews
Correct answer: To identify systemic failures and implement corrective system changes
RCA focuses on identifying the underlying system flaws — not individual fault — so that process changes can prevent recurrence of the same error.
Question 4: A patient is prescribed warfarin and is told by a friend to take vitamin K supplements to 'improve blood health.' The MTM pharmacist should explain that vitamin K supplementation will most likely:
- Potentiate warfarin's anticoagulant effect, increasing bleeding risk
- Antagonize warfarin's anticoagulant effect, reducing INR below therapeutic range (Correct answer)
- Have no effect because warfarin overrides dietary vitamin K
- Improve INR stability by providing a constant vitamin K level
Correct answer: Antagonize warfarin's anticoagulant effect, reducing INR below therapeutic range
Vitamin K is the cofactor that warfarin antagonizes; supplementing it reduces warfarin's effectiveness and can decrease INR below the therapeutic target.
Question 5: Which of the following patient counseling strategies BEST reduces the risk of accidental overdose with acetaminophen-containing combination products?
- Recommending the patient take all medications at the same time to improve adherence
- Teaching the patient to review all OTC and prescription labels for acetaminophen content (Correct answer)
- Advising the patient that acetaminophen is safe in any amount if taken as directed on each label
- Recommending switching all analgesics to ibuprofen
Correct answer: Teaching the patient to review all OTC and prescription labels for acetaminophen content
Many patients take multiple products containing acetaminophen without realizing it; teaching label reading across all products prevents unintentional cumulative overdose.
Question 6: A pharmacist performing MTM notices a patient's clonidine patch is placed on their arm instead of the upper chest or back. What is the MOST important safety implication?
- Reduced drug absorption leading to uncontrolled hypertension (Correct answer)
- Accelerated absorption causing hypotension and bradycardia
- Skin irritation without systemic effect
- Increased risk of patch detachment only
Correct answer: Reduced drug absorption leading to uncontrolled hypertension
Extremity placement can reduce clonidine absorption compared to the upper torso, potentially leading to inadequate blood pressure control.
Question 7: Which of the following best describes the role of a Medication Use Evaluation (MUE) in preventing medication errors within an MTM program?
- It audits financial claims for billing accuracy
- It systematically evaluates actual drug use against predefined therapeutic criteria to identify and correct problems (Correct answer)
- It verifies that all patients have signed informed consent forms
- It tracks adverse events reported to the FDA
Correct answer: It systematically evaluates actual drug use against predefined therapeutic criteria to identify and correct problems
A MUE is a structured quality-improvement tool that compares real-world medication use to evidence-based criteria, identifying deviations that may cause errors or suboptimal outcomes.
MTM Medication Safety & Error Prevention 5
Which of the following is the MOST effective system-level intervention to reduce medication errors compared to individual-level interventions?