Improving patient safety is a fundamental tenet of pharmacy practice. It extends beyond accurate dispensing to encompass systems-level thinking, effective communication, and a commitment to a “culture of safety.” For PharmD students, mastering concepts like medication reconciliation, root cause analysis, and quality improvement is essential for minimizing medication errors, preventing adverse drug events, and contributing to safer, more effective healthcare for all patients.
1. What is the primary goal of performing a Root Cause Analysis (RCA) after a medication error has occurred?
- To identify and punish the single individual responsible for the error.
- To identify the underlying system-based causes of the error to prevent its recurrence.
- To document the event for billing purposes only.
- To determine if the patient has grounds for a lawsuit.
Answer: To identify the underlying system-based causes of the error to prevent its recurrence.
2. The process of creating the most accurate list possible of all medications a patient is taking to avoid errors at transition points in care is known as:
- A Drug Utilization Review (DUR)
- A formulary review
- Medication Reconciliation
- A therapeutic interchange
Answer: Medication Reconciliation
3. Pharmacogenetic (PGx) testing for DPYD variant alleles is a strategy to improve patient safety for individuals receiving which class of drugs?
- Opioids
- Anticoagulants
- Fluoropyrimidine chemotherapy agents
- Beta-blockers
Answer: Fluoropyrimidine chemotherapy agents
4. A “culture of safety” in a pharmacy is best described as an environment where:
- Errors are never made.
- Individuals are encouraged to report errors and near-misses without fear of punishment, so that systems can be improved.
- The pharmacist in charge is blamed for all mistakes.
- Errors are hidden from patients and regulators.
Answer: Individuals are encouraged to report errors and near-misses without fear of punishment, so that systems can be improved.
5. SBAR is a structured communication technique used to improve safety. What does the “A” in SBAR stand for?
- Administration
- Assessment
- Acknowledgment
- Action
Answer: Assessment
6. Which of the following is an example of how automated dispensing cabinets improve patient safety in a hospital?
- By increasing the time it takes to retrieve a medication.
- By providing a single storage location for all medications, regardless of type.
- By restricting access to medications and creating an electronic record of who accessed them.
- By requiring pharmacists to manually count every dose dispensed.
Answer: By restricting access to medications and creating an electronic record of who accessed them.
7. A prospective Drug Utilization Review (DUR) is a safety mechanism that occurs:
- After the patient has experienced an adverse event.
- During the dispensing process to check for potential problems before the patient receives the drug.
- Annually for all patients in a health plan.
- Only for medications that are over-the-counter.
Answer: During the dispensing process to check for potential problems before the patient receives the drug.
8. The Joint Commission’s National Patient Safety Goals (NPSGs) are a set of guidelines designed to:
- Help healthcare organizations address specific areas of concern regarding patient safety.
- Regulate the price of prescription medications.
- Determine pharmacy staffing levels.
- Outline the curriculum for pharmacy schools.
Answer: Help healthcare organizations address specific areas of concern regarding patient safety.
9. A medication error is defined as any preventable event that may cause or lead to:
- Expected and desired therapeutic outcomes.
- A decrease in healthcare costs.
- Inappropriate medication use or patient harm.
- An increase in patient satisfaction.
Answer: Inappropriate medication use or patient harm.
10. What is a “near-miss” in the context of medication safety?
- An error that reaches the patient and causes harm.
- An error that is caught and corrected before it reaches the patient.
- An intentional violation of safety procedures.
- A side effect that is listed in the drug’s package insert.
Answer: An error that is caught and corrected before it reaches the patient.
11. Implementing DPYD pharmacogenetic testing is a strategy to prevent severe toxicity from fluoropyrimidines by:
- Increasing the dose in all patients.
- Identifying patients who are poor metabolizers of the drug.
- Ensuring the drug is administered intravenously.
- Bypassing the need for liver function monitoring.
Answer: Identifying patients who are poor metabolizers of the drug.
12. A key safety principle for high-alert medications, like insulin or heparin, is the use of:
- Independent double checks by another healthcare professional.
- Storing them next to look-alike, sound-alike medications.
- Verbal orders exclusively.
- A single, standardized dose for all patients.
Answer: Independent double checks by another healthcare professional.
13. Continuous Quality Improvement (CQI) programs, often required by state law, are designed to:
- Assign blame for medication errors.
- Provide a systematic process for identifying and reducing the frequency of medication errors.
- Document only positive patient outcomes.
- Be completed once and then never revisited.
Answer: To provide a systematic process for identifying and reducing the frequency of medication errors.
14. A key part of medication reconciliation upon hospital admission is:
- Discontinuing all of the patient’s home medications.
- Comparing the patient’s home medication list with the medications ordered in the hospital.
- Only asking the patient what medications they take, without verifying with other sources.
- Assuming the electronic medical record is always 100% accurate.
Answer: Comparing the patient’s home medication list with the medications ordered in the hospital.
15. What is the purpose of using tall man lettering (e.g., hydrOXYzine vs. hydrALAZINE) as a safety strategy?
- To make the drug names harder to read.
- To reduce confusion between look-alike, sound-alike drug names.
- It is a requirement for all generic drug labels.
- To indicate which drug is more expensive.
Answer: To reduce confusion between look-alike, sound-alike drug names.
16. Barcode medication administration (BCMA) is a technology used in hospitals to improve safety by:
- Verifying the right drug, dose, and route are being given to the right patient at the right time.
- Speeding up the medication administration process above all else.
- Eliminating the need for a pharmacist to review medication orders.
- Tracking the inventory of over-the-counter products.
Answer: Verifying the right drug, dose, and route are being given to the right patient at the right time.
17. The “Swiss Cheese Model” of accident causation suggests that errors occur when:
- A single person makes a critical mistake.
- Flaws in multiple layers of a system’s defenses align, allowing an error to pass through.
- There are too many safety protocols in place.
- The pharmacy is located in Switzerland.
Answer: Flaws in multiple layers of a system’s defenses align, allowing an error to pass through.
18. A pharmacist receiving a verbal order for a chemotherapy agent should, as a safety measure:
- Transcribe the order immediately without question.
- Refuse to accept the order under any circumstances.
- Repeat back the order to the prescriber to verify its accuracy.
- Ask the nurse to take the order instead.
Answer: Repeat back the order to the prescriber to verify its accuracy.
19. One of the National Patient Safety Goals from The Joint Commission focuses on improving the safety of:
- Using clinical alarm systems.
- Labeling all medications in procedural settings.
- Reducing the risk of healthcare-associated infections.
- All of the above.
Answer: All of the above.
20. A pharmacist can contribute to a “just culture” by:
- Focusing on system failures when an error occurs, rather than blaming an individual.
- Immediately reporting any error as an act of individual negligence.
- Hiding all near-misses to avoid documentation.
- Ignoring safety concerns raised by technicians.
Answer: Focusing on system failures when an error occurs, rather than blaming an individual.
21. An adverse drug event (ADE) differs from a medication error in that an ADE:
- Is always preventable.
- Is an injury resulting from medical intervention related to a drug, which may or may not have been caused by an error.
- Is never harmful to the patient.
- Is always caused by the patient’s non-adherence.
Answer: Is an injury resulting from medical intervention related to a drug, which may or may not have been caused by an error.
22. Which of the following is an example of a “system” that can be put in place to reduce medication errors?
- A policy requiring an independent double check for all insulin doses.
- Telling pharmacists to “be more careful”.
- Asking patients to remember their own allergies.
- Using handwritten prescriptions for all controlled substances.
Answer: A policy requiring an independent double check for all insulin doses.
23. The “five rights” of medication administration is a classic safety check. Which of the following is one of the five rights?
- Right Patient
- Right Drug
- Right Dose
- All of the above
Answer: All of the above
24. Clinical Decision Support Systems (CDSS) integrated into an EHR improve patient safety by:
- Providing alerts for potential drug interactions, allergies, or inappropriate doses.
- Automatically correcting all prescribing errors without pharmacist review.
- Slowing down the order entry process.
- Limiting the number of drugs a physician can prescribe.
Answer: Providing alerts for potential drug interactions, allergies, or inappropriate doses.
25. A pharmacist identifying that a patient’s new prescription for an ACE inhibitor is a therapeutic duplication with their current ARB is an example of:
- A prospective DUR.
- Medication reconciliation.
- A root cause analysis.
- A medication error.
Answer: A prospective DUR.
26. The main purpose of reporting near-misses is to:
- Punish the staff member who almost made the error.
- Identify weaknesses in the system before a harmful error can occur.
- Create more work for the pharmacy manager.
- Fulfill a billing requirement.
Answer: Identify weaknesses in the system before a harmful error can occur.
27. The SBAR communication tool is particularly useful for improving safety during:
- Patient handoffs between healthcare providers.
- The final verification of a prescription.
- The compounding of a non-sterile cream.
- The ordering of pharmacy supplies.
Answer: Patient handoffs between healthcare providers.
28. A key part of the “Assessment” in a Root Cause Analysis is:
- Brainstorming all possible reasons why the error occurred.
- Deciding on the punishment for the involved staff.
- Informing the patient of the error.
- Correcting the error in the computer system.
Answer: Brainstorming all possible reasons why the error occurred.
29. Implementing a “forcing function” is a powerful safety strategy. Which is an example of a forcing function?
- A computer system that will not allow a prescriber to complete an order without entering an allergy status.
- A policy that reminds pharmacists to check allergies.
- A poster in the pharmacy about common allergens.
- A continuing education program on allergies.
Answer: A computer system that will not allow a prescriber to complete an order without entering an allergy status.
30. Pharmacists improve patient safety on a systemic level by participating in:
- P&T committees to ensure safe and effective drugs are on the formulary.
- Medication safety committees within their institution.
- The development of clinical protocols and order sets.
- All of the above.
Answer: All of the above.
31. The process of medication reconciliation is most critical at what point of care?
- During a routine refill of a chronic medication.
- At every transition of care, such as hospital admission, transfer, and discharge.
- Only when a patient is starting a new antibiotic.
- When a patient is paying cash for a prescription.
Answer: At every transition of care, such as hospital admission, transfer, and discharge.
32. The use of DPYD testing before starting a fluoropyrimidine is an example of using ________ to improve safety.
- therapeutic drug monitoring
- pharmacogenomics
- a clinical decision support system
- a root cause analysis
Answer: pharmacogenomics
33. An example of a systems-based solution to prevent look-alike/sound-alike errors is:
- Telling staff to be more careful when selecting drugs.
- Physically separating the look-alike drugs on the pharmacy shelves.
- Using tall man lettering on shelf labels.
- B and C.
Answer: B and C.
34. The “R” in SBAR communication stands for Recommendation. A pharmacist’s recommendation should be:
- Vague and uncertain.
- A specific, actionable suggestion to address the identified problem.
- A question asking the physician what they want to do.
- A statement that the pharmacist is too busy to help.
Answer: A specific, actionable suggestion to address the identified problem.
35. A key goal of a CQI program is to be:
- Proactive in preventing errors, not just reactive after they occur.
- A one-time event that never needs to be repeated.
- A process focused on blaming individuals.
- Confidential and not shared with any pharmacy staff.
Answer: Proactive in preventing errors, not just reactive after they occur.
36. A pharmacist who receives an alert for a severe drug-drug interaction from the dispensing software should:
- Override the alert without investigation to save time.
- Investigate the interaction and contact the prescriber if necessary.
- Assume the alert is incorrect and dispense the prescription.
- Tell the patient to ignore the potential interaction.
Answer: Investigate the interaction and contact the prescriber if necessary.
37. One of the most common types of medication errors involves:
- The wrong patient.
- The wrong time.
- The wrong dose.
- The wrong storage conditions.
Answer: The wrong dose.
38. The Institute for Safe Medication Practices (ISMP) is an organization that primarily focuses on:
- Providing resources and promoting practices to prevent medication errors.
- Regulating pharmacy practice at the state level.
- Accrediting hospitals and healthcare systems.
- Manufacturing generic medications.
Answer: Providing resources and promoting practices to prevent medication errors.
39. A critical step in medication reconciliation is obtaining the “best possible medication history,” which involves:
- Using at least two sources to confirm a patient’s medication list (e.g., patient interview and pharmacy records).
- Only using the patient’s memory.
- Only using the list from the electronic medical record.
- Asking a family member what they think the patient takes.
Answer: Using at least two sources to confirm a patient’s medication list (e.g., patient interview and pharmacy records).
40. A pharmacist’s role in improving patient safety is an example of what professional attribute?
- Patient advocacy and stewardship.
- Entrepreneurship.
- Financial management.
- Marketing.
Answer: Patient advocacy and stewardship.
41. The failure to adjust a drug’s dose in a patient with renal insufficiency is what type of medication error?
- A dispensing error.
- A prescribing error.
- A monitoring error.
- An administration error.
Answer: A prescribing error.
42. Why is reporting “near-misses” so valuable for improving patient safety?
- It helps identify system vulnerabilities before a patient is harmed.
- It is the only type of error that needs to be reported.
- It allows managers to track employee performance.
- It has no real value.
Answer: It helps identify system vulnerabilities before a patient is harmed.
43. Which of the following is a patient-specific factor that can increase the risk of medication errors?
- Polypharmacy.
- Low health literacy.
- Communication barriers.
- All of the above.
Answer: All of the above.
44. A key strategy to improve safety in the inpatient setting is the involvement of a ________ in multidisciplinary rounds.
- marketing representative
- pharmacist
- hospital administrator
- legal counsel
Answer: pharmacist
45. The “B” in SBAR communication stands for:
- Background
- Blame
- Benefit
- Billing
Answer: Background
46. A “hard stop” alert in a CPOE system is one that:
- Can be easily overridden by the prescriber.
- Must be addressed or overridden with a reason before the order can be completed.
- Appears after the order has already been sent to the pharmacy.
- Is for informational purposes only.
Answer: Must be addressed or overridden with a reason before the order can be completed.
47. Identifying the causes that contribute to a medical error is a key objective for a student pharmacist’s development in:
- Personal and professional growth.
- Medicinal chemistry.
- Pharmacokinetics.
- Drug delivery systems.
Answer: Personal and professional growth.
48. Minimizing adverse drug events and medication errors is a core entrustable professional activity related to:
- Population health promotion.
- Practice management.
- Information mastery.
- Interprofessional collaboration.
Answer: Population health promotion.
49. A pharmacist who proactively identifies a safety risk and implements a system change is demonstrating:
- Leadership and a commitment to quality improvement.
- A lack of concern for the pharmacy’s budget.
- An overreach of their professional role.
- A focus on dispensing speed over safety.
Answer: Leadership and a commitment to quality improvement.
50. The ultimate goal of all patient safety initiatives in pharmacy is to:
- Eliminate the need for pharmacists.
- Prevent patient harm from medication use.
- Increase the number of prescriptions dispensed.
- Reduce the time spent on patient counseling.
Answer: Prevent patient harm from medication use.
I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.
Mail- Sachin@pharmacyfreak.com