Modern hospital pharmacy practice is deeply intertwined with technology and an unwavering commitment to patient safety. Health Information Technology (HIT), a key topic from the Patient Care 5 curriculum, provides powerful tools like Computerized Provider Order Entry (CPOE) and Barcode Medication Administration (BCMA) to prevent errors. However, when errors do occur, a structured process like Root Cause Analysis (RCA), as taught in the Patient Care 3 curriculum, is essential for identifying systems-based failures rather than placing individual blame. This quiz will test your knowledge on both the technology that prevents errors and the process used to learn from them.
1. A physician entering medication orders directly into the EHR is using what type of system?
- a. Barcode Medication Administration (BCMA)
- b. A smart infusion pump
- c. Computerized Provider Order Entry (CPOE)
- d. An Automated Dispensing Cabinet (ADC)
Answer: c. Computerized Provider Order Entry (CPOE)
2. The primary goal of a Root Cause Analysis (RCA) is to:
- a. Identify and discipline the individual responsible for an error.
- b. Determine the underlying systems-based reasons why an error occurred to prevent recurrence.
- c. Complete the required paperwork after an adverse event.
- d. Decide on the financial settlement for the patient.
Answer: b. Determine the underlying systems-based reasons why an error occurred to prevent recurrence.
3. Barcode Medication Administration (BCMA) technology primarily helps to ensure which of the “five rights” of medication administration?
- a. Right documentation
- b. Right reason
- c. Right patient, right drug, right dose, right route, right time
- d. Right to refuse
Answer: c. Right patient, right drug, right dose, right route, right time
4. A pharmacist receives a drug-drug interaction alert from the Clinical Decision Support System (CDSS). This is an example of what type of HIT?
- a. A tool that aids clinicians in their decision-making process.
- b. An automated dispensing cabinet.
- c. A smart pump.
- d. A documentation system only.
Answer: a. A tool that aids clinicians in their decision-making process.
5. In an RCA, a “latent error” or “latent condition” refers to:
- a. The active mistake made by the provider at the point of care.
- a. A hidden problem within a system (e.g., poor staffing, look-alike drug packaging) that contributes to errors.
- c. An error that does not cause harm.
- d. An error that is reported late.
Answer: b. A hidden problem within a system (e.g., poor staffing, look-alike drug packaging) that contributes to errors.
6. The lecture “HIT in the Hospital” is a specific topic in which course?
- a. PHA5787C Patient Care 5
- b. PHA5104 Sterile Compounding
- c. PHA5703 Pharmacy Law and Ethics
- d. PHA5784C Patient Care 4
Answer: a. PHA5787C Patient Care 5
7. A common technique used during an RCA to drill down to the fundamental cause of a problem is:
- a. The “5 Rights”
- b. The “5 Whys”
- c. The “5 A’s”
- d. The “5 P’s”
Answer: b. The “5 Whys”
8. Automated Dispensing Cabinets (ADCs) like Pyxis or Omnicell improve medication safety by:
- a. Allowing nurses to take any medication they want.
- b. Providing secure storage of medications on the nursing unit and tracking dispensing.
- c. Eliminating the need for a central pharmacy.
- d. Compounding sterile preparations.
Answer: b. Providing secure storage of medications on the nursing unit and tracking dispensing.
9. The “Root Cause Analysis” transcending concept is a specific module in which course?
- a. PHA5878C Patient Care 3
- b. PHA5163L Professional Skills Lab 3
- c. PHA5781 Patient Care I
- d. PHA5782C Patient Care 2
Answer: a. PHA5878C Patient Care 3
10. What is “alert fatigue”?
- a. The feeling of tiredness after a long shift.
- b. A condition where clinicians become desensitized to safety alerts after being exposed to a large number of non-critical or irrelevant alerts.
- c. An allergic reaction to a medication alert.
- d. A system that has too few alerts.
Answer: b. A condition where clinicians become desensitized to safety alerts after being exposed to a large number of non-critical or irrelevant alerts.
11. Which of the following is considered the “strongest” type of recommendation from an RCA?
- a. Educating staff on a new policy.
- b. Implementing a forcing function or an architectural change that makes the error impossible to commit.
- c. Adding a new warning sticker to a medication bin.
- d. Reminding staff to be more careful.
Answer: b. Implementing a forcing function or an architectural change that makes the error impossible to commit.
12. Identifying automated systems that assist in decreasing medication errors is a key objective for pharmacy students.
- a. True
- b. False
Answer: a. True
13. CPOE significantly reduces which type of medication error?
- a. Errors due to drug-drug interactions.
- b. Errors due to illegible handwriting and transcription.
- c. Errors in dose calculation.
- d. Errors due to wrong-patient selection.
Answer: b. Errors due to illegible handwriting and transcription.
14. A “Just Culture” is an environment where:
- a. Every error is punished with termination.
- b. No one is ever held accountable for their actions.
- c. There is a focus on systems improvement and a distinction between human error, at-risk behavior, and reckless conduct.
- d. Errors are not reported.
Answer: c. There is a focus on systems improvement and a distinction between human error, at-risk behavior, and reckless conduct.
15. A smart infusion pump with a drug library can prevent an error by:
- a. Alerting a nurse if a programmed rate or dose is outside of a pre-defined safe limit.
- b. Automatically selecting the correct drug.
- c. Mixing the IV bag.
- d. Placing the IV line in the patient.
Answer: a. Alerting a nurse if a programmed rate or dose is outside of a pre-defined safe limit.
16. An active error in an RCA is:
- a. The hidden systems issue.
- b. An error that is reported immediately.
- c. The “sharp end” error committed by a person closest to the patient.
- d. An error that causes no harm.
Answer: c. The “sharp end” error committed by a person closest to the patient.
17. “Interprofessional Communication & Medication Safety” is a transcending concept in the Patient Care 5 curriculum.
- a. True
- b. False
Answer: a. True
18. What is a potential “unintended consequence” or risk of implementing HIT?
- a. Increased efficiency.
- b. The creation of new types of errors (e.g., wrong selection from a dropdown menu).
- c. Perfect patient safety.
- d. Reduced need for pharmacists.
Answer: b. The creation of new types of errors (e.g., wrong selection from a dropdown menu).
19. An RCA should be performed for which of the following events?
- a. A “near miss” that was caught.
- b. A minor dispensing error with no harm.
- c. A sentinel event, such as a patient death due to a medication error.
- d. A patient complaint about the food.
Answer: c. A sentinel event, such as a patient death due to a medication error.
20. The “Introduction to Medication Errors” is a module within the Professional Practice Skills Lab II.
- a. True
- b. False
Answer: a. True
21. A pharmacist is building the drug library for a smart pump. They incorrectly enter the maximum dose for heparin. This is an example of a(n):
- a. Active error.
- b. Latent error that could lead to future patient harm.
- c. Patient-related error.
- d. Unpreventable error.
Answer: b. Latent error that could lead to future patient harm.
22. The primary focus of an RCA team should be:
- a. “Who did it?”
- b. “What happened and why did it happen?”
- c. “How can we write this up quickly?”
- d. “Was there a lawsuit filed?”
Answer: b. “What happened and why did it happen?”
23. The role of the pharmacist in health informatics can include:
- a. Managing medication-related components of the EHR.
- b. Building and maintaining drug libraries for smart pumps and ADCs.
- c. Analyzing data to improve medication use and safety.
- d. All of the above.
Answer: d. All of the above.
24. An active learning session on medication safety is part of which course?
- a. PHA5787C Patient Care 5
- b. PHA5163L Professional Skills Lab 3
- c. PHA5781 Patient Care I
- d. PHA5782C Patient Care 2
Answer: a. PHA5787C Patient Care 5
25. A pharmacist verifies a prescription for amoxicillin. The patient has a documented allergy to penicillin, but the CDSS alert is overridden. This is an example of:
- a. A potential medication error.
- b. Good clinical practice.
- c. A systems failure.
- d. Both a and c.
Answer: a. A potential medication error.
26. Which of the following is the best example of a forcing function?
- a. A warning sign on a cabinet.
- b. A connector for an enteral syringe that will not fit into an IV line.
- c. A double-check policy.
- d. An educational in-service.
Answer: b. A connector for an enteral syringe that will not fit into an IV line.
27. What is a major challenge for HIT systems in different hospitals?
- a. Interoperability, or the ability for different systems to communicate and share data effectively.
- b. A lack of electricity.
- c. A shortage of computer monitors.
- d. The systems are too simple.
Answer: a. Interoperability, or the ability for different systems to communicate and share data effectively.
28. An active learning session on RCA is part of which course module?
- a. Module 6: Cardiovascular Medication Management in the Hospital
- b. Module 1: Diabetes Mellitus
- c. Module 4: Medication Safety
- d. Module 8: Men’s Health
Answer: a. Module 6: Cardiovascular Medication Management in the Hospital
29. The use of tall man lettering (e.g., hydrOXYzine vs. hydrALAZINE) in an EHR is a strategy to:
- a. Make the screen more colorful.
- b. Reduce look-alike, sound-alike medication selection errors.
- c. Fulfill a billing requirement.
- d. Comply with a patient’s request.
Answer: b. Reduce look-alike, sound-alike medication selection errors.
30. The “Health information and informatics (HIT in Inpatient Settings)” is a lecture within the Medication Safety module.
- a. True
- b. False
Answer: a. True
31. The primary benefit of BCMA is that it:
- a. Verifies the medication at the point of administration, which is the last chance to catch an error.
- b. Verifies the medication when it is dispensed from the pharmacy.
- c. Eliminates the need for a pharmacist to check the order.
- d. Speeds up the medication administration process.
Answer: a. Verifies the medication at the point of administration, which is the last chance to catch an error.
32. Who should be included in an RCA team for a serious medication error?
- a. Only hospital administrators.
- b. Only the person who made the error.
- c. A multidisciplinary team including individuals from all parts of the medication use process.
- d. Only the patient’s family.
Answer: c. A multidisciplinary team including individuals from all parts of the medication use process.
33. An EHR can improve patient safety by providing easy access to:
- a. Patient lab results.
- b. The patient’s full medication list.
- c. Notes from other providers.
- d. All of the above.
Answer: d. All of the above.
34. A “Swiss cheese model” of accident causation suggests that:
- a. Errors are caused by a single, catastrophic failure.
- b. Errors happen when holes in multiple layers of system defenses line up.
- c. Some errors are intentional.
- d. All systems are perfect.
Answer: b. Errors happen when holes in multiple layers of system defenses line up.
35. A key part of the RCA process is to create:
- a. A detailed timeline of the events leading up to the error.
- b. A list of people to blame.
- c. A press release for the media.
- d. A new billing code.
Answer: a. A detailed timeline of the events leading up to the error.
36. A pharmacist’s role in the RCA process is valuable due to their expertise in:
- a. The medication-use system.
- b. Pharmacology and therapeutics.
- c. Potential points of failure from prescribing to administration.
- d. All of the above.
Answer: d. All of the above.
37. Recommending a policy change is considered a ____ action plan compared to a forcing function.
- a. stronger
- b. weaker
- c. equally effective
- d. more expensive
Answer: b. weaker
38. The lecture “Root Cause Analysis Reading” is part of the Patient Care 3 curriculum.
- a. True
- b. False
Answer: a. True
39. A pharmacist who identifies and reports a “near miss” is contributing to:
- a. A culture of blame.
- b. Patient safety, by allowing a system vulnerability to be fixed before it harms a patient.
- c. Unnecessary paperwork.
- d. Alert fatigue.
Answer: b. Patient safety, by allowing a system vulnerability to be fixed before it harms a patient.
40. An active learning session on HIT and RCA is part of which course?
- a. PHA5787C Patient Care 5
- b. PHA5163L Professional Skills Lab 3
- c. PHA5781 Patient Care I
- d. PHA5782C Patient Care 2
Answer: a. PHA5787C Patient Care 5
41. What is a major limitation of CPOE?
- a. It can still allow a prescriber to select the wrong drug or wrong dose from a list.
- b. It eliminates transcription errors.
- c. It is not integrated with the pharmacy system.
- d. It cannot be used for controlled substances.
Answer: a. It can still allow a prescriber to select the wrong drug or wrong dose from a list.
42. The ultimate goal of both HIT and RCA is to:
- a. Increase the complexity of healthcare.
- b. Improve patient safety and prevent harm.
- c. Reduce the number of staff needed.
- d. Fulfill regulatory requirements.
Answer: b. Improve patient safety and prevent harm.
43. A pharmacist’s ability to “accurately verify orders in an EHR” is a foundational skill for interacting with HIT.
- a. True
- b. False
Answer: a. True
44. If a BCMA system fails to scan a barcode, the nurse should:
- a. Administer the medication without scanning.
- b. Find a different medication to give.
- c. Follow a clearly defined downtime/override procedure that involves manual verification.
- d. Ask the patient if it looks like the right medication.
Answer: c. Follow a clearly defined downtime/override procedure that involves manual verification.
45. An RCA is a ________ process.
- a. prospective and preventative
- b. retrospective and reactive
- c. real-time and active
- d. continuous and ongoing
Answer: b. retrospective and reactive
46. Which of the following is a key component of a good action plan from an RCA?
- a. It is vague and has no timeline.
- b. It is specific, measurable, and has an individual assigned to be accountable for its completion.
- c. It focuses on punishing an individual.
- d. It recommends a new educational module as the only intervention.
Answer: b. It is specific, measurable, and has an individual assigned to be accountable for its completion.
47. A pharmacist is an essential member of any team dedicated to:
- a. Medication safety.
- b. Health informatics.
- c. Quality improvement.
- d. All of the above.
Answer: d. All of the above.
48. An active learning session on medication safety is part of which course?
- a. PHA5787C Patient Care 5
- b. PHA5163L Professional Skills Lab 3
- c. PHA5781 Patient Care I
- d. PHA5782C Patient Care 2
Answer: a. PHA5787C Patient Care 5
49. The overall purpose of learning about HIT and RCA is to:
- a. Understand how to use technology and process improvement to create a safer medication-use system.
- b. Become an IT specialist.
- c. Learn how to conduct investigations.
- d. Pass the final exam.
Answer: a. Understand how to use technology and process improvement to create a safer medication-use system.
50. A pharmacist who helps design and implement a CDSS alert for a high-risk drug interaction is actively participating in:
- a. A Root Cause Analysis.
- b. Patient safety and health informatics.
- c. A medication dispensing task.
- d. A compounding task.
Answer: b. Patient safety and health informatics.