PEBC Patient Safety Protocols 3 — Questions and Answers
Question 1: Which concept describes the practice of designing pharmacy systems so a single human error cannot cause patient harm?
- Root cause analysis
- Forced functions and redundancy (defense-in-depth) (Correct answer)
- Incident severity scoring
- Near-miss surveillance
Correct 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.
Question 2: A caregiver reports giving their child the wrong dose of liquid amoxicillin because they used a kitchen teaspoon. What is the best preventive strategy?
- Print a warning on the label
- Provide an oral dosing syringe calibrated in millilitres and counsel on its use (Correct answer)
- Instruct the caregiver to use only metric units
- Dispense tablets instead to avoid liquid dosing errors
Correct 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.
Question 3: When conducting a root cause analysis (RCA) after a medication error, the PRIMARY goal is to:
- Identify and discipline the pharmacist responsible
- Uncover system-level failures to prevent recurrence (Correct answer)
- Satisfy regulatory reporting requirements
- Document the financial impact of the error
Correct 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.
Question 4: A patient is prescribed digoxin 0.25 mg daily. Their serum creatinine has risen significantly since their last visit. What safety action is required?
- Continue current dose since digoxin has a wide therapeutic index
- Assess renal function and recommend dose adjustment because digoxin is renally cleared (Correct answer)
- Switch to a different cardiac glycoside automatically
- Advise the patient to take digoxin on alternate days without prescriber input
Correct 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.
Question 5: Which of the following is an example of a 'forcing function' in pharmacy safety?
- A wall poster listing high-alert medications
- A computer alert requiring the pharmacist to enter patient weight before dispensing pediatric doses (Correct answer)
- Annual staff training on medication errors
- A binder of error reports reviewed monthly
Correct 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.
Question 6: Tall Man lettering (e.g., hydrOXYzine vs. hydrALAzine) is used primarily to address which type of medication error risk?
- Calculation errors
- Look-alike/sound-alike name confusion (Correct answer)
- Incorrect route of administration
- Expired product use
Correct answer: Look-alike/sound-alike name confusion
Tall Man lettering visually differentiates the dissimilar portions of look-alike drug names to reduce selection errors.
Question 7: A patient taking phenytoin is started on fluconazole. What is the patient safety concern?
- Fluconazole reduces phenytoin absorption from the GI tract
- Fluconazole inhibits CYP2C9 and can increase phenytoin levels, risking toxicity (Correct answer)
- Fluconazole induces phenytoin metabolism, lowering its efficacy
- There is no clinically relevant interaction between these two drugs
Correct 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.
PEBC Patient Safety Protocols 3
Which concept describes the practice of designing pharmacy systems so a single human error cannot cause patient harm?