Risk Management And Error Prevention - NAPLEX
- What is a medication error according to standard patient safety definitions?
- Preventable event causing or risking inappropriate medication use. This focuses on avoidable failures in the medication use process that may lead to harm, promoting error prevention strategies.
- Which abbreviation should be avoided because it can be mistaken as "4" or "cc"?
- U (use "units" instead). Avoiding this abbreviation prevents misreading that could result in dosing errors or unit confusion.
- What is the recommended safety practice for concentrated electrolytes (for example potassium chloride) in patient care areas?
- Remove from floor stock; use premixed/standard concentrations when possible. Restricting access to concentrates prevents fatal undiluted administration, favoring safer standardized preparations.
- What is the safest response when a patient asks you to "just change" ER tablets to IR tablets for convenience?
- Do not substitute; contact prescriber because release form changes therapy. Formulation changes affect drug release and efficacy, requiring prescriber approval to maintain therapeutic integrity.
- Identify the best action if a pediatric dose seems too high for weight and indication.
- Verify weight/units and clarify dose with prescriber before filling. Pediatric doses require weight verification to avoid overdoses, necessitating prescriber confirmation for safety.
- What is the safest practice for verbal or telephone medication orders when permitted?
- Write/enter then read back and verify (read-back with confirmation). This method ensures accuracy by confirming the order through repetition and validation, minimizing communication mishaps.
- What is an adverse drug event (ADE)?
- Injury resulting from medication use (includes errors and ADRs). ADEs encompass all medication-related injuries, whether from preventable errors or inherent drug risks, to guide comprehensive safety measures.
- What is the ISMP term for medications that have an increased risk of causing significant harm if used in error?
- High-alert medications. These drugs warrant enhanced protocols due to their potential for severe consequences from even minor errors.
- What is the safest default strategy for look-alike/sound-alike (LASA) medication names?
- Use tall man lettering plus segregation and independent double-checks. Combining visual differentiation, physical separation, and verification reduces selection errors in handling similar medications.
- Which notation should be avoided because it can be read as "10 mg" when intended as "1.0 mg"?
- Trailing zero (write 1 mg, not 1.0 mg). Eliminating trailing zeros avoids tenfold dosage misreads if the decimal point is obscured or ignored.
- Which option best prevents wrong-patient errors at pickup: asking "Are you John?" or requesting identifiers?
- Request at least two identifiers (for example name and DOB). Using multiple identifiers provides reliable verification, reducing risks of misidentification compared to leading questions.
- What is the required core check before dispensing any prescription to reduce wrong-drug errors?
- Match patient, drug, dose, route, and directions to the prescription. This aligns with the five rights principle, ensuring all elements match to prevent dispensing inaccuracies.
- Identify the best immediate action if a patient reports a penicillin anaphylaxis history and amoxicillin is prescribed.
- Hold dispensing and contact prescriber to change therapy. Amoxicillin shares penicillin's structure, risking severe allergic reactions, so prescriber involvement is essential for alternative therapy.
- What does a just culture aim to balance in medication error management?
- Learning/accountability with a nonpunitive response to human error. It promotes error reporting for learning while ensuring accountability for intentional risks, fostering a safer environment.
- Identify the best action if a label prints "take 10 tablets daily" but the e-prescription states "take 1 tablet daily."
- Stop and reconcile; correct SIG to match the verified prescription. Correcting discrepancies ensures instructions match the prescription, preventing potential overdosing or underdosing errors.
- Which notation should be avoided because ".5 mg" can be misread as "5 mg"?
- Lack of a leading zero (write 0.5 mg, not .5 mg). Including leading zeros ensures decimal visibility, preventing misinterpretation of sub-unit doses as whole numbers.
- Which approach is emphasized in modern patient safety: person-based blame or system-based improvement?
- System-based improvement (focus on process design and safeguards). Modern safety prioritizes redesigning processes and adding safeguards to minimize human error rather than punishing individuals.
- What is the most appropriate action after discovering you dispensed the wrong strength but the patient has not taken any doses?
- Contact patient immediately, arrange replacement, and document/report per policy. Immediate intervention averts potential harm, with documentation supporting error analysis and policy compliance.
- What is an adverse drug reaction (ADR) as defined in patient safety practice?
- Noxious, unintended response at normal doses. This definition highlights unintended effects despite proper dosing, emphasizing pharmacovigilance in patient safety.
- What is the term for harm caused by medical care rather than the disease itself?
- Iatrogenic harm (patient harm from medical care). This term distinguishes harm from healthcare interventions, such as treatments or procedures, from that caused by the patient's underlying condition.
- What is the primary goal of a root cause analysis (RCA) after a serious event?
- Identify system causes and implement actions to prevent recurrence. RCA uncovers underlying systemic issues to develop preventive measures, shifting focus from blame to process enhancement.
- What is the primary purpose of a failure mode and effects analysis (FMEA)?
- Proactively identify process failures and mitigate risk before harm. FMEA anticipates vulnerabilities in processes, enabling risk reduction strategies prior to any adverse outcomes.
- What is the safest action when a prescriber order is unclear, incomplete, or illegible?
- Clarify with the prescriber before dispensing or administering. Seeking clarification prevents misinterpretation that could lead to harmful medication administration or dispensing.
- What is a sentinel event in healthcare risk management?
- Unexpected death or serious harm requiring immediate investigation. Such events indicate severe safety lapses, mandating thorough review to prevent future occurrences in healthcare settings.
- What is a near miss in medication safety?
- Error occurred but did not reach the patient. Intercepted errors allow for system improvements without patient impact, serving as valuable learning opportunities in safety practices.