Errors, Omissions, And Duplication - NAPLEX
- Identify the error type: A label states "take 1 tablet daily" but the prescription says "take 2 tablets daily."
- Dispensing error (incorrect directions on label). Leads to patient confusion or incorrect self-administration due to labeling discrepancies from the original order.
- What is the most appropriate pharmacist action when the route is omitted on a prescription?
- Clarify route with prescriber before dispensing. Ensures the medication is administered correctly by confirming the appropriate delivery method prior to release.
- What is the most appropriate pharmacist action when an order has a missing dose?
- Hold dispensing and clarify the dose with the prescriber. Prevents potential under- or overdosing by verifying the intended dosage to ensure safe and effective therapy.
- Identify the error type: Metoprolol succinate is dispensed instead of metoprolol tartrate.
- Dispensing error (wrong dosage form/release type). Results from substituting incorrect formulations, altering drug release and therapeutic efficacy.
- Identify the error type: A patient receives cefazolin despite an order to discontinue it yesterday.
- Duplication/continuation error (failure to discontinue). Results from ineffective communication of discontinuation, leading to unwarranted medication exposure.
- What is the most appropriate action when two active prescriptions appear to be therapeutic duplicates?
- Assess indication and clarify intended regimen with prescriber/patient. Promotes safety by evaluating necessity and confirming the intended therapy to avoid adverse effects.
- Identify the error type: A dose was due at 08:00 but was never given and no hold was documented.
- Omission error. Indicates a breakdown in administration without documented rationale, potentially leading to treatment gaps.
- Identify the error type: Warfarin is prescribed for a patient with a documented severe warfarin allergy.
- Prescribing error (contraindication/allergy). Happens when medication is ordered despite known patient risks, such as documented allergies or contraindications.
- Identify the error type: A patient is prescribed lisinopril and starts losartan without stopping lisinopril.
- Duplication error (therapeutic duplication of RAAS blockade). Involves concurrent use of similar-class agents, elevating risks like hyperkalemia without therapeutic advantage.
- Identify the error type: A technician selects hydralazine instead of hydroxyzine due to name similarity.
- Dispensing error (wrong drug; look-alike/sound-alike). Common with look-alike/sound-alike drugs, preventable by enhanced verification and storage practices.
- What is a prescribing error in the medication-use process?
- Incorrect drug, dose, route, frequency, or directions in the prescription. Occurs during the prescribing phase when the prescriber specifies inappropriate medication details, leading to potential harm if not intercepted.
- What is the most appropriate pharmacist action when the frequency is omitted on a prescription?
- Clarify frequency with prescriber before dispensing. Avoids risks of toxicity or subtherapeutic effects by confirming proper dosing intervals with the prescriber.
- Identify the error type: A refill is processed for a medication that was previously discontinued.
- Duplication/continuation error (inappropriate continuation). Stems from failure to update records, resulting in unnecessary or potentially harmful continued therapy.
- What is the best definition of a near miss in pharmacy practice?
- An error detected and corrected before reaching the patient. Highlights opportunities for system improvements by identifying errors intercepted before patient exposure.
- What is a dispensing error in the medication-use process?
- Medication dispensed differs from what was prescribed. Involves pharmacy staff selecting, preparing, or labeling medication incorrectly, deviating from the prescriber's order.
- What is the most appropriate pharmacist action when an order is illegible or ambiguous?
- Do not guess; clarify with prescriber before dispensing/verification. Prevents misinterpretation risks by requiring clarification to ensure accurate medication delivery.
- What is the most appropriate pharmacist action when a prescriber signature is missing where required?
- Do not dispense; obtain a valid prescriber authorization. Maintains legal and safety standards by requiring authentication to prevent unauthorized or fraudulent prescriptions.
- What is a duplication error in medication therapy?
- Unnecessary duplicate therapy with same or similar pharmacologic effect. Involves prescribing multiple agents with overlapping effects unnecessarily, increasing risk of adverse reactions without benefit.
- What is the best definition of an adverse drug event (ADE)?
- Patient harm resulting from medication use, including medication errors. Encompasses harm from both preventable errors and inherent drug risks, informing safety protocols.
- What is an omission error in medication administration?
- A scheduled dose is not given and is not clinically justified. Represents a failure in the administration process without valid justification, potentially disrupting therapeutic outcomes.
- What is the best definition of an adverse drug reaction (ADR)?
- Noxious, unintended response at normal doses (not necessarily an error). Refers to inherent drug responses not tied to errors, distinguishing from preventable medication mishaps.
- What is the most appropriate action when a medication history suggests an omission of a chronic medication on admission?
- Reconcile medications and request an order if clinically appropriate. Facilitates continuity of care through reconciliation, addressing potential oversights in admission orders.
- Identify the error type: A patient receives two doses because the medication was administered twice.
- Duplication error (double administration). Arises from redundant administration due to communication or system failures, risking overdose.
- What is the most appropriate pharmacist action when the quantity is omitted on an outpatient prescription?
- Clarify intended quantity or days supply with the prescriber. Ensures compliance with regulations and matches the dispensed amount to the therapeutic need for outpatient care.
- Identify the error type: A patient receives insulin glargine twice daily because the order was entered twice.
- Duplication error (duplicate order entry). Occurs due to redundant order entry in systems, leading to excessive dosing and potential hypoglycemia.