Patient Safety Protocols Flashcards

A pharmacist receives a prescription for warfarin 10 mg daily for a 78-year-old patient with a history of falls, atrial fibrillation, and chronic kidney disease (CrCl 22 mL/min). The patient's current INR is 1.4. Which action BEST reflects patient safety protocol in this high-risk scenario?

Answer: Contact the prescriber to clarify the dose, document the clinical concern about falls risk and renal impairment affecting warfarin metabolism, and recommend a lower starting dose with more frequent INR monitoring

In a high-risk patient with multiple compounding factors (advanced age, falls risk, CrCl <30 mL/min affecting warfarin clearance, and a subtherapeutic INR suggesting underdosing may be intentional or the dose is being escalated), the pharmacist's duty is to contact the prescriber, document clinical concerns, and collaborate on a safe plan. Pharmacists cannot unilaterally substitute anticoagulants (option C), and simply dispensing without raising documented concerns (options A and D) fails the standard of care for a high-risk medication. The key safety principle is proactive prescriber communication with documented clinical rationale.

During a medication reconciliation at hospital admission, a pharmacist discovers that a patient has been taking both celecoxib 200 mg daily (prescribed by a rheumatologist) and low-dose ASA 81 mg daily (self-initiated). The patient is scheduled for elective knee surgery in 5 days. Which patient safety concern is MOST clinically urgent to communicate to the surgical team?

Answer: Celecoxib, despite its COX-2 selectivity, combined with ASA produces additive platelet inhibition that significantly increases perioperative bleeding risk and may require holding both agents pre-operatively

While celecoxib has minimal COX-1-mediated platelet inhibition alone, when combined with ASA (which irreversibly inhibits COX-1), the combination produces clinically significant additive antiplatelet effects. Both agents typically need to be held before elective surgery — celecoxib for at least 2 days and ASA (when not for secondary prevention) for 7–10 days. Option B describes a real drug interaction concern (loss of ASA cardioprotection), but it is not the most urgent perioperative safety issue. Option D incorrectly dismisses celecoxib's contribution in the combination context. This reconciliation finding requires urgent surgical team notification given the 5-day window.

A pharmacist is reviewing a discharge prescription for a patient with newly diagnosed epilepsy. The prescription reads: 'phenytoin 100 mg TID.' The patient is also on enteral nutrition (EN) via nasogastric tube. Which patient safety intervention is MOST appropriate?

Answer: Contact the prescriber to discuss the significant reduction in phenytoin absorption caused by EN, recommend holding EN for 1–2 hours before and after each dose, flushing the NG tube before and after administration, and arranging close therapeutic drug monitoring (TDM) with free phenytoin levels

Phenytoin has a well-documented interaction with enteral nutrition: the protein in EN formulas significantly reduces phenytoin absorption, leading to subtherapeutic levels and seizure breakthrough risk. The suspension form does NOT eliminate this interaction. The safe protocol requires: (1) holding EN for 1–2 hours before and after each phenytoin dose, (2) flushing the tube with water before and after, and (3) monitoring free phenytoin levels (not total, as phenytoin is highly protein-bound and disease states alter binding). Option D is incorrect — phenytoin is not contraindicated with EN, but requires careful management. The pharmacist should not substitute medications unilaterally.

A pharmacist receives a verbal order from a physician for 'morphine 2 mg IV q4h PRN pain' for a post-surgical patient. Upon reviewing the chart, the pharmacist notes the patient has a documented allergy to morphine listed as 'respiratory depression.' Which response BEST reflects patient safety protocol?

Answer: Contact the prescriber to clarify the nature of the 'allergy' — determine if it was a true immune-mediated hypersensitivity or an adverse drug reaction (ADR)/intolerance — document the clarification, and recommend an alternative opioid such as hydromorphone with appropriate dose conversion and monitoring if morphine is contraindicated

The allergy documentation 'respiratory depression' is ambiguous — it may represent an ADR/intolerance (a predictable pharmacological effect at high doses) rather than a true IgE-mediated allergy. This distinction is safety-critical: a true allergy may require avoiding all phenanthrene opioids, while an ADR means the risk is manageable with appropriate monitoring and may not preclude opioid use. The pharmacist must clarify with the prescriber, document the discussion, and if morphine is truly contraindicated, recommend alternatives (e.g., hydromorphone, fentanyl) with proper equianalgesic dosing. Option D is unsafe because unilateral therapeutic substitution of controlled substances without prescriber authorization is not within the pharmacist's scope, and cross-reactivity among opioids requires prescriber involvement.

A pharmacy receives a prescription for methotrexate 15 mg ONCE WEEKLY for a patient with rheumatoid arthritis. The dispensing label is generated showing 'methotrexate 15 mg — take as directed.' A technician fills the prescription and is ready for pharmacist verification. Which action MOST effectively prevents the most dangerous dispensing error associated with this medication?

Answer: Confirm the weekly dosing frequency is explicitly printed on the dispensing label (e.g., 'Take 15 mg ONCE WEEKLY on [specific day]'), counsel the patient verbally on weekly dosing, and provide written patient information reinforcing that this is NOT a daily medication

Methotrexate is one of the most commonly involved medications in fatal dispensing errors, with the most catastrophic mistake being patients taking it daily instead of weekly. The label 'take as directed' is dangerously vague for this high-alert drug. Patient safety protocol requires that the dosing frequency (ONCE WEEKLY) be explicitly stated on the label, with the specific day if possible, combined with verbal counseling and written materials. Option C (auxiliary label + info sheet) is helpful but insufficient without the explicit label correction. Option D is incorrect — 15 mg weekly is a standard rheumatology dose, not an oncology dose requiring special confirmation. Option A fails to address the label deficiency, which is the primary safety risk.

A pharmacist is counseling a 34-year-old woman who has just been prescribed isotretinoin for severe nodular acne. She states she is 'not sexually active' and declines to enroll in the iPLEDGE (or equivalent Canadian risk management) program, citing privacy concerns. She requests the pharmacist dispense the medication without program enrollment. Which response is MOST appropriate?

Answer: Decline to dispense isotretinoin, explain that the risk management program enrollment is a mandatory condition of dispensing regardless of sexual activity status, and offer to address her specific privacy concerns within the program's framework

Isotretinoin is a known teratogen with the potential to cause severe birth defects, and in Canada, its dispensing is governed by a mandatory risk management program (similar to iPLEDGE in the US). Enrollment is a non-negotiable condition of dispensing for all patients of childbearing potential — 'not sexually active' status does not exempt a patient, as sexual activity status can change and the consequences of fetal exposure are catastrophic. There is no mechanism for prescriber waivers from the program. The pharmacist's role is to decline dispensing, explain the non-negotiable nature of program enrollment, and compassionately address the patient's privacy concerns within the existing framework. Dispensing without enrollment would violate Health Canada's risk minimization requirements and expose the pharmacist to serious professional and legal liability.