Medication Errors and Types Quiz

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Questions and Answers

What major report brought national attention to errors in medicine and highlighted the need for improved patient safety?

The Joint Commission Report

The Patient Safety Initiative

To Err Is Human (correct)

The NCCMERP Guidelines

Approximately how many deaths per year are attributed to medication errors according to the information provided?

44,000

7,000 (correct)

98,000

150,000

Which of the following errors resulted from a chemotherapy mix-up?

A child received a tenfold overdose of antidepressants

A four-fold daily overdose over four days (correct)

Infant deaths due to heparin mix-ups

An overdose of penicillin

What is the definition of a medication error according to NCCMERP?

A preventable event causing harm with medication Signup and view all the answers

What type of error occurs when a drug not ordered for a patient is administered?

Wrong drug error Signup and view all the answers

Which scenario represents a medication error involving packaging mix-ups?

Heparin vials with similar packaging cause overdoses Signup and view all the answers

What was the cause of the child's death related to medication errors mentioned in the document?

Incorrect administration of penicillin Signup and view all the answers

Which of the following medication error types is not included in the definitions provided?

Equipment malfunction errors Signup and view all the answers

What is a possible cause of an extra dose error?

The nurse was confused by medication directions. Signup and view all the answers

Which type of error occurs when a dose of medication is not given as directed?

Omission error Signup and view all the answers

What is the result of a wrong dose or wrong strength error?

A patient receives an incorrect dosage of medication. Signup and view all the answers

Which scenario best exemplifies a wrong route error?

A patient receives an oral medication when it was prescribed intravenously. Signup and view all the answers

What specific medication error could arise due to a pharmacist misreading a label?

Wrong dose or wrong strength error Signup and view all the answers

In which situation might a wrong time error typically occur?

A nurse becomes overworked and forgets the timing of the dose. Signup and view all the answers

What might lead to a wrong route error during medication administration?

Nurse confusion during medication preparation. Signup and view all the answers

Which of these options is NOT a potential cause of a medication error?

Nurse taking a break during medication rounds. Signup and view all the answers

What is a possible cause for a patient receiving their medication two hours late?

The nurse was busy and could not give the dose on time. Signup and view all the answers

What does a dosage form error involve?

A patient receiving a medication in a dosage form that was not intended. Signup and view all the answers

Which abbreviation can lead to serious medication errors due to misinterpretation?

U (unit) Signup and view all the answers

What does the abbreviation QD risk being misinterpreted as?

QID (four times daily) Signup and view all the answers

How should a dosage of 2.0 mg be written to avoid misinterpretation?

2 mg Signup and view all the answers

What effect can the abbreviation Q.O.D have if misinterpreted?

Overdose due to confusion with QID. Signup and view all the answers

What should always be written out to avoid potential medication errors?

Abbreviations like 'unit' and 'every day' Signup and view all the answers

What is advised regarding trailing zeros in dosage amounts?

They should be avoided. Signup and view all the answers

What is the recommended way to write a dose of digoxin that is less than 1 mg?

digoxin 0.25 mg Signup and view all the answers

Which abbreviation can be confused with magnesium sulfate and should be written out completely?

MS Signup and view all the answers

What is the potential risk associated with using 'mg' instead of 'mcg' for levothyroxine dosing?

Overdosing the patient Signup and view all the answers

What is a recommended practice to avoid confusion between similar drug names?

Open the bottle in front of the patient Signup and view all the answers

Which symbol is often misinterpreted for 'less than' and should be written out in full?

, Signup and view all the answers

Which of the following abbreviations for hydrocortisone can be misread as a different medication?

HCT Signup and view all the answers

Which unsafe abbreviation for milliliters is often mistaken, prompting a recommendation to use 'mL' instead?

cc Signup and view all the answers

What common error can occur by misinterpreting the abbreviation for hydrochloric acid (HCl)?

Administering potassium chloride instead Signup and view all the answers

Which dosage is equivalent to 250 mcg of levothyroxine?

2.5 mg Signup and view all the answers

What could have contributed to the pharmacist's error in dispensing warfarin?

A trailing zero is present. Signup and view all the answers

What common error may arise from the abbreviations MS, MSO4, and MgSO4?

Misinterpretation as different medications. Signup and view all the answers

Which statement is true regarding communication practices in medication error prevention?

Poor communication can be considered a latent defect. Signup and view all the answers

What is a major consequence of a pharmacy error involving total parenteral nutrition?

Potential for life-threatening situations. Signup and view all the answers

What is one reason for dismissing a pharmacy technician involved in medication errors?

All of the above. Signup and view all the answers

Which aspect of the prescription for warfarin was most detrimental to patient safety?

The prescription was for a high dose. Signup and view all the answers

What is the impact of leading zeros according to best practices in pharmacy?

They are unnecessary and can cause confusion. Signup and view all the answers

Study Notes

Medication Error Problem

A study performed in 2000 estimated that 44,000 to 98,000 deaths per year are caused by medical errors, with 7,000 resulting from medication errors.
The Institute of Medicine (IOM) report To Err Is Human brought the problem of errors to national attention.
The report called for action to improve patient safety.

### Types of Medication Errors

Wrong drug error: A drug that's not ordered for a patient is given.
- Example: Furosemide 40 mg orally meant for a patient with an antibiotic.
Extra dose error: A patient receives more doses than ordered.
- Example: A patient receives their medication 5 times instead of 3.
Omission error: A dose is skipped, though it was ordered.
- Example: A patient is supposed to receive digoxin 0.25 mg orally in the morning but doesn't receive it.
Wrong dose or wrong strength error: Wrong dose or strength is administered.
- Example: Patient should receive warfarin 0.5 mg but receives 5 mg.
- Example: Patient should receive timolol 0.25% but receives 0.5%.
Wrong route error: A patient receives a dose through a route that's not ordered.
- Example: Patient should receive prochlorperazine 10 mg intramuscularly but receives it intravenously.
Wrong time error: Patient doesn't receive a dose at the time it was ordered.
- Example: A patient with diabetes receives insulin 2 hours after breakfast instead of before.
Wrong dosage form error: A patient receives a dose in a form that's not intended.
- Example: Nicotinic acid 500 mg tablets are ordered but the patient receives 500 mg slow-release capsules.

Common Error Hazards

Dangerous abbreviations: Numerous common abbreviations have been associated with errors.
- U, IU: Should write out ‘unit(s)’ as ‘U’ can be mistaken as a number.
- QD, Q.D., qd, q.d.: Should write out ‘daily’ as it can be misinterpreted as ‘QID’, meaning four times daily.
- Q.O.D, QOD, qod: Should write out ‘every other day’ as it can be interpreted as ‘QID’, meaning four times daily.
- Trailing Zero: Avoid trailing zeros, for example, warfarin 2 mg instead of 2.0 mg
- Lack of Leading Zero: Include leading zero, so the dose is written as Digoxin 0.25 mg.
- MS, MSO4: Should write out ‘morphine sulfate’ and ‘magnesium sulfate’ to avoid confusion.

Other Confusing Symbols

cc: Use mL instead of cc.
mg: Use mcg or write out ‘micrograms’ instead of mg to avoid confusion with milligrams.
,,, or .: Use “less than” or “greater than” in place of symbols.
HCT: Write out ‘hydrocortisone’ as it can be misinterpreted as hydrochlorothiazide.
HCl: Write out ‘hydrochloric’ as it can be misinterpreted as KCl, potassium chloride.
Sound-a-like or look-a-like drug names: The ISMP has a list of confusing drug names.
- Examples: Amitriptyline and aminophylline, Cisplatin and carboplatin, K-Dur and Cardura.

Examples of Common Medication Errors

Example 1:
- A pharmacist is presented with a prescription for 250 mcg of levothyroxine.
- The accurate dosage would be 0.25 mg, but 2.5 mg was dispensed due to conversion mistakes.
Example 2:
- Community pharmacist mistakenly dispenses 10 mg of Warfarin instead of 1.0 mg.
- This leads to the patient experiencing internal bleeding, almost leading to death.
- This error was likely caused by a trailing zero in 1.0 mg, which could be misinterpreted as 10 mg.
Example 3:
- A hospital pharmacy mistakes a total parenteral nutrition solution for a cardioplegic solution for coronary bypass surgery.
- This highlights the importance of identifying the root cause of the error during root cause analysis.

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Description

Test your knowledge about medication errors, their impact on patient safety, and different types of errors that can occur in medical practice. This quiz will cover key concepts highlighted in the To Err Is Human report and provide real-world examples to enhance your understanding.