Patient Safety Protocols Flashcards

A pharmacist receives a verbal order from a physician for 'morphine 2.5 mg IV q4h PRN pain' for a post-operative patient. The pharmacy's ISMP-aligned policy requires read-back verification for all narcotic verbal orders. The physician is in an active surgical procedure and unavailable for immediate callback. Which action BEST aligns with patient safety protocols?

Answer: Contact the covering physician or resident to review, verify, and co-sign the verbal order before dispensing

ISMP Canada guidelines and most institutional policies permit a covering physician or resident to verify and co-sign a verbal order when the ordering physician is temporarily unavailable. This maintains the safety intent of read-back (independent verification by a licensed prescriber) without delaying necessary patient care or pulling a surgeon out of an active procedure. Simply documenting a failed attempt (A) does not fulfil the safety requirement. Paging the surgeon out of surgery (B) creates unnecessary risk to another patient. There is no blanket 'emergency override' for routine post-op verbal narcotic orders (D).

During a medication reconciliation on admission, a pharmacist discovers that a patient's home medication list includes warfarin 5 mg daily and the admitting intern has ordered warfarin 2 mg daily without documenting a reason for the dose change. The patient's INR on admission is 2.4 (therapeutic range 2.0–3.0). The intern is not available. What is the MOST appropriate next step?

Answer: Contact the most responsible physician or attending to clarify the intended dose change before dispensing either dose

Warfarin is an ISMP high-alert medication. An unexplained dose discrepancy between a home dose and an admission order — without documented clinical rationale — is a medication reconciliation safety gap. The safest action is to escalate to the most responsible physician (MRP) or attending for clarification before dispensing. Dispensing the home dose without verification (C) assumes the intern made an error, which may not be true (e.g., the MRP intended dose reduction). Dispensing the lower order (A) rationalizes a potentially unintentional error. Holding entirely (B) is unnecessarily disruptive when clarification is possible and the INR is therapeutic.

A community pharmacist receives a prescription for methotrexate 15 mg DAILY for a patient with no documented cancer diagnosis in the patient profile. The pharmacist contacts the prescribing dermatologist, who confirms the indication is psoriasis and insists the daily dosing is intentional. Which response reflects BEST patient safety practice?

Answer: Decline to dispense the daily regimen, document the clinical concern, and request a written order confirming daily dosing with the prescriber's acknowledgement that this deviates from standard psoriasis dosing

Methotrexate for non-oncologic indications (psoriasis, rheumatoid arthritis) is dosed WEEKLY, not daily. Daily dosing is one of the most documented fatal medication errors in Canada (multiple ISMP Canada safety bulletins). A verbal confirmation alone does not adequately protect the patient, as it may represent a prescriber error not caught in the moment. The pharmacist should document the clinical concern formally, decline to dispense the daily regimen, and request a written acknowledgement that daily dosing is intentional — this creates a documented safety checkpoint. Option A relies on verbal confirmation alone for a known fatal error pattern. Option B is premature before documenting the concern formally. Option D's counselling note does not correct an inherently dangerous order.

A hospital pharmacist is performing prospective order review and notices that a patient with a documented penicillin allergy (reaction: anaphylaxis) has been ordered cefazolin 1 g IV for surgical prophylaxis. The allergy was entered in the EMR 3 years ago with no further details. The surgery is scheduled in 90 minutes. Which action represents the MOST complete patient safety response?

Answer: Contact the surgical team to obtain a detailed allergy history and, if the reaction was IgE-mediated anaphylaxis, recommend an alternative prophylactic agent such as clindamycin or vancomycin

Current evidence indicates that the true cross-reactivity between penicillins and cephalosporins is approximately 1–2% in penicillin-allergic patients, and is driven by shared side-chain structures rather than the beta-lactam ring alone. Cefazolin shares no side-chain similarity with most penicillins, making its cross-reactivity risk very low. However, when the documented reaction is anaphylaxis — a severe IgE-mediated response — the risk-benefit calculation changes, and clarification of the allergy history is essential before proceeding. The correct approach is to contact the surgical team, characterize the allergy (true IgE-mediated vs. intolerance), and recommend an alternative (clindamycin or vancomycin) if the anaphylaxis history is confirmed. Automatic override without allergy review (A) ignores the severity of the documented reaction. Unilaterally substituting without prescriber communication (C) exceeds scope without a collaborative process. Delaying surgery for allergy testing (D) is not feasible or necessary in 90 minutes.

A pharmacist working in a long-term care (LTC) facility reviews a medication administration record and finds that a resident with moderate dementia has been receiving lorazepam 1 mg BID for 14 months without a documented reassessment or deprescribing plan. The facility has recently adopted the Choosing Wisely Canada recommendations. Which patient safety concern BEST characterizes this situation and what is the MOST appropriate pharmacist intervention?

Answer: This represents a potentially inappropriate medication use in an elderly patient with dementia per Beers Criteria and Choosing Wisely Canada; the pharmacist should initiate a collaborative deprescribing discussion with the prescriber and care team, including a taper plan and monitoring parameters

Benzodiazepines in elderly patients with dementia are classified as potentially inappropriate medications by both the American Geriatrics Society Beers Criteria and Choosing Wisely Canada (which explicitly recommends against benzodiazepines in older adults). Risks include cognitive worsening, falls, paradoxical agitation, and physical dependence. After 14 months of continuous use, abrupt discontinuation without a taper risks withdrawal seizures. The pharmacist's role is to initiate a collaborative deprescribing process — not to unilaterally discontinue (B) or delay indefinitely (A). A fall assessment alone (D) does not address the root pharmacological safety concern. The gold standard is a structured taper plan developed with the prescriber, with behavioural non-pharmacological alternatives explored.

During a clinical pharmacy round, a pharmacist notes that a 68-year-old patient with CKD stage 4 (eGFR 22 mL/min/1.73 m²) has been ordered gabapentin 600 mg TID for neuropathic pain. The patient has also developed new-onset confusion and somnolence over the past 48 hours. The most responsible physician attributes the mental status change to the patient's underlying infection. What is the pharmacist's MOST appropriate patient safety contribution?

Answer: Recommend empiric dose reduction of gabapentin based on renal function — eGFR 22 suggests the current dose likely produces supratherapeutic accumulation — and propose a renally-adjusted regimen as a contributing or alternative explanation for the neurological changes

Gabapentin is renally eliminated and requires dose adjustment for eGFR below 30 mL/min. At eGFR 22, the recommended gabapentin dose is substantially reduced (typically 100–300 mg TID or less, per Canadian product monographs and renal dosing references such as the Kidney Disease: Improving Global Outcomes guidelines). Supratherapeutic gabapentin levels in renal impairment cause CNS toxicity manifesting as somnolence, confusion, and dizziness — the exact symptoms this patient is experiencing. The pharmacist's role is to raise this as an alternative or contributing explanation, provide a renally-adjusted dosing recommendation, and support clinical decision-making. The physician's attribution to infection may be partially correct but does not rule out drug toxicity. Option A incorrectly interprets 'maximum labelled dose' as applicable to all renal function categories. Option C overstates certainty — 'definitive' causal relationship cannot be established without drug level confirmation. Pregabalin (D) also requires renal dose adjustment at eGFR 22 and is not a straightforward solution.