PEBC Patient Safety Protocols 2 — Questions and Answers
Question 1: A pharmacist receives a prescription for methotrexate 2.5 mg tablets with instructions to take 'one tablet daily.' What is the most important safety intervention?
- Dispense as written since the dose is low
- Contact the prescriber to clarify — methotrexate for non-oncology use is typically dosed weekly, not daily (Correct answer)
- Add a warning label and dispense
- Refer the patient to their physician without dispensing
Correct answer: Contact the prescriber to clarify — methotrexate for non-oncology use is typically dosed weekly, not daily
Methotrexate for rheumatoid arthritis or psoriasis is dosed weekly; daily dosing is a well-known, potentially fatal prescribing error.
Question 2: Which error-reporting system principle is central to improving patient safety in pharmacy practice?
- Punitive reporting to deter future errors
- Blame-free, voluntary reporting to identify systemic issues (Correct answer)
- Mandatory reporting only for near-miss events
- Reporting only errors that cause patient harm
Correct answer: Blame-free, voluntary reporting to identify systemic issues
Blame-free, voluntary reporting encourages disclosure of errors and near-misses, enabling systemic improvements without fear of punishment.
Question 3: A patient is prescribed warfarin and asks if they can take naproxen for knee pain. What is the primary safety concern?
- Naproxen reduces warfarin absorption
- NSAIDs displace warfarin from plasma proteins and increase bleeding risk (Correct answer)
- Naproxen accelerates warfarin metabolism via CYP2C9
- There is no clinically significant interaction
Correct answer: NSAIDs displace warfarin from plasma proteins and increase bleeding risk
NSAIDs such as naproxen potentiate warfarin's anticoagulant effect and increase GI bleeding risk through antiplatelet and anticoagulant mechanisms.
Question 4: In the ISMP high-alert medication list, which insulin formulation is considered highest risk due to look-alike/sound-alike confusion?
- Regular insulin (Humulin R)
- Insulin glargine (Lantus) confused with other insulin types (Correct answer)
- NPH insulin (Humulin N)
- Insulin aspart (NovoRapid)
Correct answer: Insulin glargine (Lantus) confused with other insulin types
Insulin glargine is frequently confused with NPH insulin due to similar appearance, leading to hypoglycemia or hyperglycemia when the wrong product is dispensed.
Question 5: A pharmacy technician brings a filled prescription to the pharmacist for final verification. Which checking technique best reduces dispensing errors?
- Verify only the drug name and quantity
- Use the PINCH method: Patient, Indication, Name of drug, Count, Hard stops
- Check the label matches the original prescription using an independent double-check (Correct answer)
- Trust the technician's filling and sign off quickly
Correct answer: Check the label matches the original prescription using an independent double-check
An independent double-check by the pharmacist comparing the filled product against the original prescription is the gold standard for catching dispensing errors.
Question 6: Which strategy is most effective for preventing wrong-patient errors during prescription dispensing?
- Match patient last name only
- Use at least two patient identifiers (e.g., full name and date of birth) (Correct answer)
- Use the prescription number as the sole identifier
- Match patient address and phone number
Correct answer: Use at least two patient identifiers (e.g., full name and date of birth)
Using two independent identifiers such as full name and date of birth minimizes the risk of dispensing to the wrong patient.
Question 7: A pharmacist notices a drug recall notice for a lot number already dispensed to patients. What is the immediate priority action?
- Wait for the manufacturer to contact patients directly
- Quarantine remaining stock and notify affected patients to return the product (Correct answer)
- Continue dispensing until official Health Canada guidance arrives
- Document the lot number and monitor for adverse event reports
Correct answer: Quarantine remaining stock and notify affected patients to return the product
The pharmacist must quarantine remaining recalled stock immediately and proactively contact patients to prevent continued use of a potentially unsafe product.
PEBC Patient Safety Protocols 2
A pharmacist receives a prescription for methotrexate 2.5 mg tablets with instructions to take 'one tablet daily.' What is the most important safety intervention?