Patient Safety Protocols Flashcards
7 cards from real PEBC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Safety Protocols flashcards as text
Which concept describes the practice of designing pharmacy systems so a single human error cannot cause patient harm?
Answer: Forced functions and redundancy (defense-in-depth)
Defense-in-depth uses forced functions, redundancies, and barriers so that multiple safeguards must all fail before an error reaches the patient.
A caregiver reports giving their child the wrong dose of liquid amoxicillin because they used a kitchen teaspoon. What is the best preventive strategy?
Answer: Provide an oral dosing syringe calibrated in millilitres and counsel on its use
Providing an oral syringe in mL and counselling on its use eliminates the household spoon variability that causes paediatric dosing errors.
When conducting a root cause analysis (RCA) after a medication error, the PRIMARY goal is to:
Answer: Uncover system-level failures to prevent recurrence
RCA focuses on systemic and process failures — not individual blame — to implement durable solutions that prevent similar errors.
A patient is prescribed digoxin 0.25 mg daily. Their serum creatinine has risen significantly since their last visit. What safety action is required?
Answer: Assess renal function and recommend dose adjustment because digoxin is renally cleared
Digoxin is primarily renally eliminated; reduced kidney function raises serum digoxin levels and the risk of toxicity, requiring dose reassessment.
Which of the following is an example of a 'forcing function' in pharmacy safety?
Answer: A computer alert requiring the pharmacist to enter patient weight before dispensing pediatric doses
A forcing function is a system design that physically prevents an action from proceeding without a required step, such as mandatory weight entry.
Tall Man lettering (e.g., hydrOXYzine vs. hydrALAzine) is used primarily to address which type of medication error risk?
Answer: Look-alike/sound-alike name confusion
Tall Man lettering visually differentiates the dissimilar portions of look-alike drug names to reduce selection errors.
A patient taking phenytoin is started on fluconazole. What is the patient safety concern?
Answer: Fluconazole inhibits CYP2C9 and can increase phenytoin levels, risking toxicity
Fluconazole is a potent CYP2C9 inhibitor; co-administration with phenytoin can cause significant elevation of phenytoin plasma levels and toxicity.