PEBC Patient Safety Protocols 4 — Questions and Answers
Question 1: Which statement best describes the concept of 'medication reconciliation' as a patient safety practice?
- Reviewing a patient's financial eligibility for their medications
- Comparing a patient's current medication orders to all prior medication lists to identify discrepancies (Correct answer)
- Counselling patients on how to take each medication
- Verifying that prescriptions are signed by an authorized prescriber
Correct answer: Comparing a patient's current medication orders to all prior medication lists to identify discrepancies
Medication reconciliation involves systematically comparing medication lists at care transitions to identify and resolve omissions, duplications, and errors.
Question 2: A patient on lithium therapy presents with tremors, nausea, and confusion. Serum lithium is 1.8 mmol/L. What is the pharmacist's role?
- Advise the patient to drink more water and recheck in a week
- Recognize signs of lithium toxicity and urgently refer to the prescriber or emergency services (Correct answer)
- Suggest holding one dose and monitoring
- Recommend switching to an alternative mood stabilizer
Correct answer: Recognize signs of lithium toxicity and urgently refer to the prescriber or emergency services
Lithium levels above 1.5 mmol/L with neurotoxic symptoms constitute toxicity requiring urgent medical evaluation.
Question 3: Which practice MOST reduces the risk of a wrong-drug error when filling a prescription manually?
- Storing all medications alphabetically on shelves
- Separating look-alike products and using auxiliary labels to highlight differences (Correct answer)
- Having the same technician fill and verify every prescription
- Using only brand names when labelling medications
Correct answer: Separating look-alike products and using auxiliary labels to highlight differences
Physically separating look-alike products and adding auxiliary labels disrupts the visual pattern that leads to wrong-drug selection.
Question 4: Under ISMP Canada guidelines, which abbreviation is on the 'Do Not Use' list because it has caused fatal errors?
- PO (by mouth)
- U (for units) (Correct answer)
- QID (four times daily)
- PRN (as needed)
Correct answer: U (for units)
The abbreviation 'U' for units has been misread as '0,' '4,' or '4u,' causing ten-fold dosing errors with insulin and other medications.
Question 5: A pharmacist is counselling a patient newly prescribed an ACE inhibitor. Which adverse effect requires immediate safety counselling regarding when to seek emergency care?
- Dry cough
- Angioedema of the lips, tongue, or throat (Correct answer)
- Mild dizziness on standing
- Increased urination
Correct answer: Angioedema of the lips, tongue, or throat
Angioedema is a rare but life-threatening ACE inhibitor adverse effect that can cause airway obstruction and requires immediate emergency care.
Question 6: What does the Swiss Cheese Model of accident causation illustrate in the context of pharmacy safety?
- That errors are inevitable and cannot be prevented
- That multiple layers of defenses each have weaknesses, and errors occur when holes align (Correct answer)
- That pharmacists are the sole responsible party for all medication errors
- That technology eliminates all human error
Correct answer: That multiple layers of defenses each have weaknesses, and errors occur when holes align
The Swiss Cheese Model shows that harm occurs only when the gaps (holes) in multiple independent safety barriers align simultaneously, emphasizing layered defenses.
Question 7: A pharmacist discovers a dispensing error after the patient has already taken the medication. What is the correct order of actions?
- Document the error in the pharmacy log only and move on
- Assess patient harm immediately, inform the patient, contact the prescriber, and document/report per protocol (Correct answer)
- Notify the pharmacy owner before contacting the patient
- Wait to see if the patient calls back with a complaint
Correct answer: Assess patient harm immediately, inform the patient, contact the prescriber, and document/report per protocol
Patient safety requires immediate harm assessment and honest disclosure to the patient, followed by prescriber notification and formal incident documentation.
PEBC Patient Safety Protocols 4
Which statement best describes the concept of 'medication reconciliation' as a patient safety practice?