Patient Safety Protocols Flashcards

A pharmacist receives a verbal order from a physician for 'morphine 10 mg IV q4h PRN pain' for a post-surgical patient. The patient's chart shows a documented allergy to codeine with a reaction described as 'nausea and vomiting.' Which action best reflects evidence-based patient safety practice?

Answer: Clarify the nature of the codeine reaction with the patient and prescriber before dispensing, and document the clinical decision made

While nausea and vomiting to codeine is typically a side effect rather than a true IgE-mediated allergy, the pharmacist cannot unilaterally dismiss a documented allergy without clinical assessment. The safe practice is to clarify the reaction type with the patient and prescriber, determine the clinical risk, and document the decision. Cross-reactivity among opioids is generally low but not zero, and the documentation step is a critical patient safety obligation under PEBC standards.

A pharmacist is reviewing a new prescription for methotrexate 15 mg orally ONCE WEEKLY for rheumatoid arthritis in a 68-year-old patient with an eGFR of 28 mL/min/1.73m². The patient's profile also shows they are taking trimethoprim-sulfamethoxazole (TMP-SMX) DS daily for recurrent UTI prophylaxis. Which statement MOST accurately reflects the patient safety concern?

Answer: Both TMP-SMX and methotrexate inhibit dihydrofolate reductase, and their combination significantly increases the risk of severe bone marrow suppression, especially in this renally impaired patient

TMP-SMX inhibits dihydrofolate reductase (as does methotrexate) and also reduces renal tubular secretion of methotrexate, leading to methotrexate toxicity. In a patient with CKD stage 4 (eGFR 28), methotrexate clearance is already substantially reduced, amplifying accumulation risk. The combination dramatically increases the risk of life-threatening pancytopenia and mucositis. This is a well-documented, high-severity drug-drug interaction requiring intervention — not merely monitoring.

During a medication reconciliation at hospital admission, a pharmacist discovers a patient has been self-administering a herbal supplement containing St. John's Wort daily for depression. The patient is being admitted for a heart transplant and is about to start cyclosporine immunosuppression. What is the most critical patient safety action?

Answer: Immediately alert the transplant team, as St. John's Wort is a potent CYP3A4/P-gp inducer that can dramatically reduce cyclosporine levels and precipitate acute graft rejection

St. John's Wort is a powerful inducer of CYP3A4 and P-glycoprotein, both of which are critical to cyclosporine metabolism and transport. Co-administration can reduce cyclosporine AUC by 50% or more, putting a transplant patient at immediate risk of acute rejection. This is classified as a contraindicated combination in transplant pharmacology. The pharmacist must act proactively, not reactively — alerting the transplant team before cyclosporine is initiated is the only safe course. The enzyme induction effect also persists for 1–2 weeks after St. John's Wort is stopped.

A pharmacist filling a prescription for lithium carbonate 300 mg TID notices the patient is a 52-year-old woman who was recently started on hydrochlorothiazide 25 mg daily for hypertension by a different prescriber. She reports feeling 'unusually tired and shaky' over the past week. Her last lithium level (drawn 3 weeks ago) was 0.7 mEq/L. What is the MOST likely safety concern driving her symptoms?

Answer: Reduced sodium reabsorption caused by thiazide diuresis leading to compensatory renal lithium retention and toxicity, even though her previous level was therapeutic

Thiazide diuretics cause sodium depletion, which triggers compensatory proximal tubular reabsorption of both sodium and lithium (they share the same transporter). This reduces lithium clearance and can increase serum lithium levels by 25–50%, pushing previously therapeutic patients into the toxic range. The patient's symptoms of fatigue and tremor are classic early signs of lithium toxicity. Her level of 0.7 mEq/L was therapeutic three weeks ago, but hydrochlorothiazide was started after that measurement. A repeat lithium level is urgently needed.

A hospital pharmacist receives a stat verbal order from an ICU physician: 'Give KCl 40 mEq IV push NOW' for a critically ill patient with a potassium of 2.6 mEq/L and new ECG changes. What is the correct response?

Answer: Clarify the order immediately with the physician, as concentrated KCl IV push is a high-alert medication error that can cause fatal cardiac arrest; the correct route is controlled IV infusion with cardiac monitoring

Concentrated potassium chloride given by IV push is a known cause of fatal medication errors and is classified as a high-alert medication by ISMP. Even in hypokalemia with ECG changes, IV KCl must never be administered as a bolus push — it causes immediate cardiac arrest due to hyperkalemia at the myocardium. The maximum safe peripheral infusion rate is typically 10 mEq/hour, and central lines allow up to 20 mEq/hour with continuous cardiac monitoring. The pharmacist's obligation is to immediately clarify and correct this order, not to execute it. This falls under the pharmacist's duty of independent professional judgment.

A community pharmacist is counselling a patient newly prescribed warfarin 5 mg daily following a DVT. The patient mentions they have been eating large daily servings of kale, spinach, and broccoli as part of a new 'heart-healthy diet' started two weeks ago, and asks if this is fine. Which response BEST reflects evidence-based patient safety counselling?

Answer: Advise the patient to maintain a consistent intake of vitamin K-rich foods rather than eliminating them, explain the warfarin-vitamin K interaction, and ensure close INR follow-up during this diet change period

The safe and evidence-based approach is consistency, not elimination. Large fluctuations in vitamin K intake destabilize INR far more than a consistently high intake, which can be compensated for with appropriate warfarin dose titration. Telling a patient to avoid all vitamin K-rich vegetables is overly restrictive, nutritionally harmful, and unnecessary. The patient should understand that sudden changes in their diet going forward can affect their INR. Close INR monitoring during the current dietary transition period is essential, as the new diet was started two weeks ago and may already be affecting anticoagulation status. DOACs are a clinical decision, not a first-line pharmacist recommendation for a diet concern.