MTM Transitions of Care & Reconciliation 2 — Questions and Answers
Question 1: A patient is discharged from the hospital on warfarin 5 mg daily, but their outpatient record shows warfarin 2.5 mg daily. What is the pharmacist's FIRST action?
- Dispense the higher dose as ordered by the hospital
- Contact the discharging physician to clarify the intended dose (Correct answer)
- Dispense the lower outpatient dose until the physician is available
- Ask the patient which dose they prefer
Correct answer: Contact the discharging physician to clarify the intended dose
Dose discrepancies require immediate clarification with the prescriber before dispensing to prevent patient harm.
Question 2: During a post-discharge MTM visit, which tool is MOST useful for identifying medications the patient is actually taking versus what was prescribed?
- Patient's insurance claims history
- Brown bag medication review (Correct answer)
- Electronic health record discharge summary
- Pharmacy dispensing records alone
Correct answer: Brown bag medication review
A brown bag review allows the pharmacist to physically inspect all medications the patient has at home, capturing the most accurate picture of actual use.
Question 3: Which patient population is at HIGHEST risk for medication errors during care transitions?
- Young adults with acute infections
- Elderly patients with multiple chronic conditions on polypharmacy (Correct answer)
- Pediatric patients receiving a single antibiotic
- Healthy adults undergoing elective surgery
Correct answer: Elderly patients with multiple chronic conditions on polypharmacy
Elderly patients with polypharmacy are most vulnerable due to complex regimens, cognitive changes, and multiple prescribers.
Question 4: A pharmacist conducting medication reconciliation at hospital admission finds a patient takes an herbal supplement not listed on any prior record. What should the pharmacist do?
- Ignore it since herbal supplements are not medications
- Document it and assess for drug-herb interactions (Correct answer)
- Advise the patient to stop all herbal supplements immediately
- Report it only if the patient is on anticoagulants
Correct answer: Document it and assess for drug-herb interactions
All supplements must be documented and evaluated for potential interactions with prescribed medications.
Question 5: Which of the following BEST describes the purpose of the 'teach-back' method during care transition counseling?
- Teaching the patient to self-administer injections
- Confirming patient understanding by asking them to explain information back (Correct answer)
- Providing written instructions for the patient to review at home
- Testing the patient on pharmacology concepts
Correct answer: Confirming patient understanding by asking them to explain information back
Teach-back confirms comprehension by having the patient restate information in their own words, identifying gaps in understanding.
Question 6: A patient transitioning from inpatient to skilled nursing facility (SNF) care has insulin orders that differ between settings. Who bears PRIMARY responsibility for reconciling these orders?
- The SNF nursing staff alone
- The pharmacist at the receiving facility
- The healthcare team at both the sending and receiving facilities working together (Correct answer)
- The patient's family members
Correct answer: The healthcare team at both the sending and receiving facilities working together
Safe medication reconciliation during handoffs requires collaboration between both the sending and receiving care teams.
Question 7: After a patient is discharged from the ED with a new beta-blocker prescription, the MTM pharmacist discovers the patient already takes a beta-blocker at home. What is this an example of?
- Therapeutic duplication identified during medication reconciliation (Correct answer)
- An appropriate dose escalation
- A drug-drug interaction requiring monitoring only
- A formulary substitution by the ED pharmacist
Correct answer: Therapeutic duplication identified during medication reconciliation
Prescribing the same drug class twice creates therapeutic duplication, a common error caught during medication reconciliation.
MTM Transitions of Care & Reconciliation 2
A patient is discharged from the hospital on warfarin 5 mg daily, but their outpatient record shows warfarin 2.5 mg daily.
What is the pharmacist's FIRST action?