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WorksheetsSLTech- Chapter 14 Medication Safety and Error Prevention
Total questions: 52
Worksheet time: 33mins
Match each medication safety term to its correct definition.
Medication Error
Any preventable event that may cause or lead to inappropriate medication use or patient harm.
Adverse Drug Event (ADE)
Injury resulting from the use of a drug, including allergic reactions or overdoses.
Adverse Drug Reaction (ADR)
A non-preventable, harmful, and unintended response to a normal drug dose.
Near Miss / Close Call
An error that was caught before reaching the patient.
Which of the following is an example of a high-alert medication?
Insulin
A medication error
Root Cause Analysis (RCA)
LASA Medications
What is the purpose of Tall-Man Lettering in medication safety?
To distinguish look-alike/sound-alike drugs such as DOBUTamine vs. DOPamine
To analyze serious adverse events and identify underlying problems
To encourage learning and accountability instead of punishment
To identify high-risk medications
Which definition best describes Just Culture in the context of medication safety?
Encourages learning and accountability instead of punishment for human error
A structured method used to analyze serious adverse events
A non-preventable, harmful, and unintended response to a normal drug dose
FDA-required safety programs for certain high-risk medications
LASA Medications are best described as:
Look-Alike, Sound-Alike drugs that can be easily confused
Drugs with a higher risk of causing significant patient harm
Any preventable event that may cause or lead to inappropriate medication use
A strategy to distinguish similar drug names
Which term refers to FDA-required safety programs for certain high-risk medications such as Clozapine and Isotretinoin?
Risk Evaluation and Mitigation Strategy (REMS)
High-Alert Medications
Root Cause Analysis (RCA)
Adverse Drug Event (ADE)
Root Cause Analysis (RCA) is used in medication safety to:
Analyze serious adverse events and identify underlying problems
Distinguish look-alike/sound-alike drugs
Encourage learning and accountability
Identify high-risk medications
Which of the following is NOT one of the Five Rights of Medication Safety?
Right Patient
Right Storage
Right Dose
Right Route
Select all settings where medication errors can occur.
At home
In clinical settings
Only in pharmacies
Only in hospitals
Which of the following is often true about medication errors?
They are often unreported unless identified by healthcare providers or through adverse events or reactions.
They are always reported immediately by patients.
They only occur with prescription drugs.
They never result in patient harm.
Match each type of medication error to its correct description.
Compliance Error
Patient fails to follow the prescribed regimen.
Deteriorated Drug Error
Administering expired or improperly stored medication.
Improper Dose Error
Wrong dosage given (e.g., 325 mg instead of 500 mg).
Monitoring Error
Failure to monitor medication effects, side effects, or dosage adjustments.
Omission Error
Missed doses without proper documentation or reasoning.
Match each medication error category to its description.
Category A
Circumstances that could cause errors but no error occurs
Categories B-D
Errors that occur but do not cause harm to the patient
Categories E-H
Errors that result in temporary or permanent harm, requiring intervention or hospitalization
Category I
Errors that result in the patient’s death
Medication errors fall into three main categories. Which of the following is NOT one of those categories?
Monitoring Errors
Prescribing Errors
Dispensing Errors
Administration Errors
Match each type of medication error to its example.
Prescribing Errors
Incorrect medication strength or illegible handwriting
Dispensing Errors
Sound-alike or look-alike drugs during prescription interpretation
Administration Errors
Ear medications applied to the eye or oral medications given intravenously
Which of the following is a common issue leading to medication errors, especially in interpreting drug names, strengths, and dosages?
Illegible handwriting
Incorrect storage temperature
Expired medications
Patient allergies
What is one way e-prescribing helps reduce medication errors?
It sends prescriptions electronically to pharmacies, reducing errors from illegible handwriting.
It eliminates the need for pharmacists to check drug interactions.
It allows patients to choose their own medication strength.
It prevents all types of medication errors.
Which of the following is NOT an example of a prescribing error?
Administering ear medication to the eye
Incorrect strength of a medication
Quantity and refill information omitted
Route of administration not specified
Which of the following is an example of a dispensing error?
Incorrect prescription interpretation
Ear medications being placed in the eye
Oral medications given intravenously
Failure to document medication administration records accurately
Which of the following is an example of an administration error?
Incorrect calculations
Intravenous (IV) syringes used to measure oral medications
Incorrect drug utilization evaluation
Incorrect prescription interpretation
Which error type involves failure to document medication administration records accurately?
Dispensing Error
Sound-alike/Look-alike Drug Error
Administration Error
Calculation Error
Why is it important to avoid using intravenous (IV) syringes to measure oral medications?
It can lead to incorrect dosing and administration errors
It ensures accurate measurement of oral medications
It prevents dispensing errors
It improves documentation accuracy
Which organization tracks medication errors and provides recommendations to reduce them, especially in nonhospital environments?
World Health Organization (WHO)
National Coordinating Council for Medication Error Reporting and Prevention (MERP)
Centers for Disease Control and Prevention (CDC)
American Society of Health-System Pharmacists (ASHP)
Which of the following is a common cause of medication errors according to the American Society of Health-System Pharmacists (ASHP)?
Excessive workload
Strict supervision
Advanced technology
Limited patient contact
Which of the following is an example of an individual performance lapse that could lead to a medication error?
A pharmacist misreads a prescription due to distraction
A medication is unavailable in the pharmacy
A drug label is ambiguous
A piece of equipment malfunctions
Which of the following is NOT listed as a common cause of medication errors by the American Society of Health-System Pharmacists (ASHP)?
Inappropriate use of abbreviations in prescriptions
Labeling errors
Frequent patient education sessions
Illegible handwriting
According to the American Society of Health-System Pharmacists (ASHP), what is a risk associated with look-alike or sound-alike drug names?
They can be mistaken for each other, leading to medication errors
They are always prescribed together
They are only used in hospitals
They are tracked by the CDC
Match each type of error cause to its description:
Human Factors
Misreading or misremembering information, automatic behavior, and complacency during repetitive tasks
Environmental Factors
Stress from high workloads, fast-paced environments, workplace noise, and multitasking
Medication-Related Issues
Look-alike or sound-alike medications, similar packaging or labeling, and illegible handwriting on prescriptions
Physical Challenges
Difficult-to-read labels due to small print or unclear design
Which organization reviews around 300 drug names annually to reduce confusion between look-alike and sound-alike drugs?
FDA
CDC with the World Health Organization
National Institutes of Health
American Medical Association
What is the main goal of the FDA's efforts to review and test drug names for similarity?
To prevent medication errors caused by confusing drug names
To increase the number of approved drug names each year
To reduce the cost of drug development
To promote the use of generic drugs
When deciding to approve a new drug, what must be evaluated?
Whether its benefits outweigh the risks to the patient
Whether it is the most cost-effective option
Whether it has the shortest development time
Whether it is recommended by pharmacists
If the risks of a drug are significant, what may be required to ensure patient safety?
Additional labeling or a Risk Evaluation and Mitigation Strategy (REMS)
Immediate withdrawal from the market
Mandatory generic substitution
Exclusive distribution through hospitals
Which organizations recommend the use of tall man lettering to reduce confusion between look-alike drug names?
ISMP and The Joint Commission (TJC)
FDA and CDC
World Health Organization and NIH
American Pharmacists Association and ISMP
Which of the following strategies is used to prevent medication errors related to drug labeling?
Using color coding, tall man lettering, and boldface lettering
Increasing the number of prescriptions handled per hour to improve efficiency
Reducing the use of stickers and segregating bins in pharmacies
Encouraging the use of similar names for new drugs
How are state boards of pharmacy addressing the risks of excessive workload?
By recommending sufficient staffing, mandatory breaks, and eliminating productivity quotas
By increasing the number of prescriptions handled per hour
By reducing the number of staff in pharmacies
By encouraging longer working hours for pharmacists
Match each drug combination to its potential effect.
ACE inhibitors + spironolactone
Increase serum potassium levels
Ciprofloxacin + multivitamin
Reduce antibiotic absorption
Digoxin + verapamil or amiodarone
May lead to toxicity
Theophylline + quinolones
Result in theophylline toxicity
Why are drug interactions a common source of errors in seniors and severely ill patients?
They often take multiple medications and have age-related changes in metabolism.
They are less likely to follow medication instructions.
They have stronger immune systems.
They rarely experience side effects.
Which laboratory values must be closely monitored in patients taking warfarin to prevent clotting or bleeding?
Prothrombin time (PT) and international normalized ratio (INR)
Serum potassium and sodium levels
Blood glucose and hemoglobin A1c
White blood cell count and platelet count
Which of the following drugs increases the risk of bleeding when taken with warfarin?
Aspirin
Vitamin K
Soybean oil
Cranberry juice
Select all supplements that increase the risk of bleeding when taken with warfarin.
Gingko biloba
Garlic
St. John’s wort
Vitamin K
Ginseng
Which foods can reduce warfarin's effectiveness?
Green vegetables rich in vitamin K and soybean or canola oils
Cranberry juice and garlic
St. John’s wort and quinolones
Aspirin and phenytoin
Which of the following is a recommended approach by pharmacy organizations to address errors in the pharmacy?
Emphasizing open error reporting without fear of retaliation
Increasing reprimands for every mistake
Reducing the number of prescriptions filled
Avoiding the identification of root causes
Match each pharmacy organization to its role in error reporting.
Allows healthcare professionals to report adverse drug events and product issues.
MedWatch
Addresses vaccine-related errors. Reports are shared with the FDA to help prevent future incident
VERP
Collects and analyzes medication error reports to improve safety.
ISMP
Joint ISMP and FDA system for confidential error reporting.
MERP
Worker safety, particularly for hazardous drug exposure.
OSHA
Why does fear of blame in the pharmacy hinder error analysis?
It contributes to stress and discourages open discussion of mistakes
It encourages staff to report errors more frequently
It leads to immediate process improvements
It reduces the number of prescriptions filled
Which of the following is a possible consequence for individuals involved in severe drug errors?
Loss of professional license or legal penalties
Receiving a bonus for honesty
Promotion to a higher position
No change in professional status
Which population groups are affected by age-related errors in medication use?
Both elderly and pediatric populations
Only elderly populations, especially those with chronic diseases
Only pediatric populations, particularly infants and toddlers
Only adults over the age of 65
Why does the risk of drug-drug and drug-food interactions increase among older adults?
Older adults often take multiple medications for chronic conditions such as osteoporosis, cardiovascular disease, and diabetes.
Older adults have a slower metabolism, which makes drug interactions more likely.
Older adults are more likely to forget to take their medications on time.
Older adults only take prescription medications and avoid over-the-counter drugs.
What is a common misconception among seniors regarding over-the-counter (OTC) drugs?
Seniors often believe OTC drugs are safe and can be mixed with prescription medications, which can lead to complications.
Seniors think OTC drugs are more effective than prescription drugs for chronic conditions.
Seniors believe OTC drugs are only for minor illnesses and never cause side effects.
Seniors assume OTC drugs are always recommended by healthcare professionals.
Match each chronic condition to its description.
Osteoporosis
A condition characterized by weakened bones
Cardiovascular disease
A condition affecting the heart and blood vessels
Diabetes
A condition involving problems with blood sugar regulation
What is polypharmacy and why is it a concern for the elderly?
Polypharmacy refers to the use of multiple medications, which increases the risk of drug-drug and drug-food interactions in the elderly.
Polypharmacy is the use of herbal supplements along with prescription drugs, which is always safe for the elderly.
Polypharmacy means taking only one medication at a time, which reduces risks for the elderly.
Polypharmacy is a term for mixing food and drugs, which is not a concern for the elderly.
How do medication errors in the elderly compare to those in pediatric populations?
Both elderly and pediatric populations experience age-related medication errors.
Medication errors are only common in the elderly, not in pediatric populations.
Pediatric populations are more likely to experience medication errors than the elderly.
Medication errors are rare in both elderly and pediatric populations.
What can happen when seniors mix prescription and over-the-counter medications?
Mixing prescription and OTC medications can lead to complications due to mistaken beliefs about safety.
Mixing prescription and OTC medications always improves health outcomes.
Mixing prescription and OTC medications has no effect on seniors' health.
Mixing prescription and OTC medications is recommended for treating chronic conditions.
Which of the following best describes drug-drug and drug-food interactions?
Drug-drug interactions occur when multiple medications affect each other's action, and drug-food interactions happen when food changes the effect of a medication.
Drug-drug interactions only happen with prescription drugs, while drug-food interactions only happen with OTC drugs.
Drug-drug interactions are always beneficial, while drug-food interactions are always harmful.
Drug-drug interactions and drug-food interactions are rare and not a concern for the elderly.
