Patients with Chronic Kidney Disease (CKD) are a high-risk population uniquely vulnerable to medication errors due to impaired drug clearance, polypharmacy, and complex treatment regimens. Ensuring patient safety in this group is a “transcending concept” in the PharmD curriculum, linking knowledge from courses like Patient Care 4 on renal disease with medication safety principles taught throughout the program. This quiz will focus on identifying, preventing, and managing common medication errors in CKD, from failing to adjust doses to prescribing contraindicated medications, all critical skills for the vigilant pharmacist.
1. What is the most common type of medication error in patients with Chronic Kidney Disease (CKD)?
- a. Dispensing the wrong medication.
- b. Failure to adjust the dose of a renally cleared drug.
- c. Incorrect route of administration.
- d. Incorrect timing of administration.
Answer: b. Failure to adjust the dose of a renally cleared drug.
2. A patient with CKD Stage 4 (eGFR 25 mL/min/1.73m²) is prescribed metformin. This is a potential medication error due to the increased risk of:
- a. Severe hypoglycemia
- b. Lactic acidosis
- c. Hepatotoxicity
- d. Acute pancreatitis
Answer: b. Lactic acidosis
3. Why should long-term use of NSAIDs be avoided in patients with CKD?
- a. They can worsen hypertension, cause sodium/fluid retention, and precipitate acute kidney injury.
- b. They are not effective for pain in this population.
- c. They have a high risk of causing hyperkalemia.
- d. They are rapidly cleared by the kidneys, leading to therapeutic failure.
Answer: a. They can worsen hypertension, cause sodium/fluid retention, and precipitate acute kidney injury.
4. A patient with ESRD on hemodialysis is prescribed enoxaparin at a standard dose for VTE treatment. Why is this a safety concern?
- a. Enoxaparin is not an anticoagulant.
- b. The drug is rapidly cleared by dialysis, leading to ineffectiveness.
- c. Enoxaparin and its metabolites accumulate in severe renal dysfunction, increasing the risk of major bleeding.
- d. It will cause severe hypertension.
Answer: c. Enoxaparin and its metabolites accumulate in severe renal dysfunction, increasing the risk of major bleeding.
5. A pharmacist receives a prescription for gabapentin 900 mg TID for a patient with an eGFR of 20 mL/min/1.73m². This dose is likely too high and could lead to what adverse effect?
- a. Liver failure
- b. Neurotoxicity (e.g., confusion, somnolence)
- c. Severe rash
- d. Hypertension
Answer: b. Neurotoxicity (e.g., confusion, somnolence)
6. The “Dosing in Renal Dysfunction” is a specific “Transcending Concept” in which course?
- a. PHA5784C Patient Care 4
- b. PHA5104 Sterile Compounding
- c. PHA5703 Pharmacy Law and Ethics
- d. PHA5878C Patient Care 3
Answer: a. PHA5784C Patient Care 4
7. A patient with ESRD is prescribed morphine for pain. The pharmacist should be concerned about the accumulation of which active metabolite?
- a. Morphine-3-glucuronide (M3G)
- b. Morphine-6-glucuronide (M6G)
- c. Normeperidine
- d. Both a and b
Answer: d. Both a and b
8. For a medication that is significantly cleared by hemodialysis, giving the dose before the dialysis session would be an error leading to:
- a. Increased toxicity
- b. Subtherapeutic drug levels and potential treatment failure.
- c. No significant consequence.
- d. A hypertensive crisis.
Answer: b. Subtherapeutic drug levels and potential treatment failure.
9. Which of the following antibiotics requires significant dose adjustment in nearly all stages of CKD?
- a. Doxycycline
- b. Ceftriaxone
- c. Azithromycin
- d. Vancomycin
Answer: d. Vancomycin
10. A patient is prescribed a phosphate binder. A counseling error would be to tell the patient to:
- a. Take it with meals.
- b. Take it on an empty stomach.
- c. Expect constipation as a side effect.
- d. Separate it from other medications like levothyroxine.
Answer: b. Take it on an empty stomach.
11. The management of Chronic Kidney Disease is a topic within the Patient Care 4 curriculum.
- a. True
- b. False
Answer: a. True
12. A patient with CKD and hyperkalemia is prescribed lisinopril. What is the most immediate safety concern?
- a. The lisinopril will not be effective.
- b. The lisinopril will worsen the hyperkalemia.
- c. The patient will develop a cough.
- d. The patient will become hypotensive.
Answer: b. The lisinopril will worsen the hyperkalemia.
13. A “near-miss” medication error is an error that:
- a. Reached the patient and caused harm.
- b. Reached the patient but did not cause harm.
- c. Was caught before it reached the patient.
- d. Was made by a student.
Answer: c. Was caught before it reached the patient.
14. A pharmacist’s most important role in preventing medication errors in CKD is:
- a. To accurately assess a patient’s renal function and screen all medications for necessary dose adjustments.
- b. To only dispense medications that do not require renal dosing.
- c. To perform a daily pill count for every patient.
- d. To personally administer all medications.
Answer: a. To accurately assess a patient’s renal function and screen all medications for necessary dose adjustments.
15. The use of which pain medication is contraindicated in renal failure due to the accumulation of a neurotoxic metabolite (normeperidine)?
- a. Hydromorphone
- b. Fentanyl
- c. Meperidine
- d. Methadone
Answer: c. Meperidine
16. An “Introduction to Medication Errors” is a module within the Professional Practice Skills Lab II.
- a. True
- b. False
Answer: a. True
17. A patient with CKD Stage 5 is given a standard starting dose of digoxin. This could lead to what toxicity?
- a. Bradycardia, heart block, and visual disturbances.
- b. Severe hypertension.
- c. Lactic acidosis.
- d. Acute liver failure.
Answer: a. Bradycardia, heart block, and visual disturbances.
18. A “prescribing cascade” is a type of medication error where:
- a. A drug’s dose is tapered too quickly.
- b. A drug side effect is misinterpreted as a new medical condition, and a second drug is prescribed to treat it.
- c. A medication is prescribed without an indication.
- d. The wrong drug is dispensed.
Answer: b. A drug side effect is misinterpreted as a new medical condition, and a second drug is prescribed to treat it.
19. A patient on an ESA develops hypertension. What is the appropriate initial action?
- a. Increase the ESA dose.
- b. Consider holding the ESA dose and initiating or titrating antihypertensive therapy.
- c. Stop the ESA permanently.
- d. Start a second ESA.
Answer: b. Consider holding the ESA dose and initiating or titrating antihypertensive therapy.
20. The curriculum includes a transcending concept on “Patient Safety/Med Errors.”
- a. True
- b. False
Answer: a. True
21. Which direct oral anticoagulant (DOAC) is most significantly affected by renal impairment and is contraindicated at low CrCl levels?
- a. Apixaban
- b. Rivaroxaban
- c. Dabigatran
- d. All are equally affected.
Answer: c. Dabigatran
22. A pharmacist fails to recognize that a new prescription for trimethoprim/sulfamethoxazole will interact with a patient’s ACE inhibitor. This could lead to what life-threatening electrolyte abnormality?
- a. Severe hyponatremia
- b. Severe hyperkalemia
- c. Severe hypocalcemia
- d. Severe hypermagnesemia
Answer: b. Severe hyperkalemia
23. Why is it an error to use the Cockcroft-Gault equation for drug dosing during an episode of AKI?
- a. Because the serum creatinine is not at a steady state, leading to an inaccurate estimation of renal function.
- b. The equation is only for patients with normal renal function.
- c. The equation does not use serum creatinine.
- d. It is not an error; it is the most accurate method.
Answer: a. Because the serum creatinine is not at a steady state, leading to an inaccurate estimation of renal function.
24. The renal system module in Patient Care 4 covers dosing in renal dysfunction.
- a. True
- b. False
Answer: a. True
25. A patient with CKD is prescribed magnesium citrate as a laxative. The pharmacist should intervene because:
- a. It is not an effective laxative.
- b. It will cause diarrhea.
- c. Magnesium can accumulate to toxic levels in patients with poor renal function.
- d. It can cause hyperkalemia.
Answer: c. Magnesium can accumulate to toxic levels in patients with poor renal function.
26. Which of the following is an example of a systems-based approach to preventing medication errors in CKD?
- a. Blaming the nurse for administering the wrong dose.
- b. Building automated alerts into the EHR for drugs requiring renal dose adjustments.
- c. Requiring all pharmacists to work 12-hour shifts.
- d. Firing any prescriber who makes a dosing error.
Answer: b. Building automated alerts into the EHR for drugs requiring renal dose adjustments.
27. A patient with a history of gout and CKD Stage 4 is prescribed colchicine at the standard dose. This is an error because:
- a. Colchicine does not treat gout.
- b. The dose must be reduced in renal impairment to prevent severe neuromuscular toxicity.
- c. Colchicine is nephrotoxic.
- d. The patient should receive allopurinol instead.
Answer: b. The dose must be reduced in renal impairment to prevent severe neuromuscular toxicity.
28. An active learning session on the renal system, including CKD, is part of which course?
- a. PHA5784C Patient Care 4
- b. PHA5163L Professional Skills Lab 3
- c. PHA5781 Patient Care I
- d. PHA5782C Patient Care 2
Answer: a. PHA5784C Patient Care 4
29. The failure to check a patient’s most recent renal function labs before verifying an order for a renally-cleared drug is a potential:
- a. Patient safety event
- b. Near-miss
- c. Process error
- d. All of the above
Answer: d. All of the above
30. The “Dosing in Patients with Renal Dysfunction” module is part of the Drug Therapy Individualization course.
- a. True
- b. False
Answer: a. True
31. A patient with ESRD on dialysis misses their Monday dialysis session. The pharmacist knows that the dose of their renally cleared medications for that day may need to be:
- a. Increased
- b. Held or reduced to prevent toxicity.
- c. Unchanged.
- d. Doubled at the next session.
Answer: b. Held or reduced to prevent toxicity.
32. Which of the following is a “high-alert” medication that requires extreme caution when dosing in patients with CKD?
- a. Acetaminophen
- b. Docusate
- c. Digoxin
- d. Calcium carbonate
Answer: c. Digoxin
33. What is the safest pain medication choice for a patient with ESRD?
- a. Meperidine
- b. Morphine
- c. Tramadol
- d. Fentanyl or hydromorphone (with caution)
Answer: d. Fentanyl or hydromorphone (with caution)
34. A pharmacist’s prospective drug utilization review (DUR) is a critical safety net for preventing:
- a. Dosing errors in patients with renal dysfunction.
- b. Drug-drug interactions.
- c. Therapeutic duplication.
- d. All of the above.
Answer: d. All of the above.
35. A “culture of safety” encourages reporting medication errors in order to:
- a. Punish the individual who made the error.
- b. Improve systems and processes to prevent future errors.
- c. Increase paperwork.
- d. Satisfy a legal requirement only.
Answer: b. Improve systems and processes to prevent future errors.
36. A patient is prescribed glyburide for diabetes and subsequently develops CKD Stage 4. Continued use of glyburide is an error because:
- a. It is not effective for diabetes.
- b. Its active metabolite accumulates in renal failure, causing prolonged and severe hypoglycemia.
- c. It causes hyperkalemia.
- d. It is nephrotoxic.
Answer: b. Its active metabolite accumulates in renal failure, causing prolonged and severe hypoglycemia.
37. Which of the following is the most important piece of information for safely dosing drugs in a CKD patient?
- a. Their diet preference.
- b. Their most recent estimated GFR or CrCl.
- c. Their home address.
- d. Their insurance status.
Answer: b. Their most recent estimated GFR or CrCl.
38. The management of drug-induced kidney disease is a lecture in the Patient Care 4 curriculum.
- a. True
- b. False
Answer: a. True
39. A patient is prescribed both spironolactone and an ACE inhibitor. This represents a risk for a drug-drug interaction leading to:
- a. Severe hypotension
- b. Severe hyperkalemia
- c. Acute kidney injury
- d. Both b and c
Answer: d. Both b and c
40. An active learning session covering CKD is part of which course module?
- a. Module 7: Renal System
- b. Module 1: PUD and GERD
- c. Module 4: Gastrointestinal Infections
- d. Module 5: Nutrition & Weight Management
Answer: a. Module 7: Renal System
41. The use of aluminum-containing antacids in patients with ESRD is an error due to the risk of:
- a. Aluminum toxicity (e.g., bone disease, encephalopathy).
- b. Severe diarrhea.
- c. Hypercalcemia.
- d. Metabolic acidosis.
Answer: a. Aluminum toxicity (e.g., bone disease, encephalopathy).
42. Which of the following is a “near miss”?
- a. A pharmacist dispenses the wrong strength of lisinopril, and the patient takes it.
- b. A pharmacist catches that the dose of vancomycin is too high for the patient’s renal function before it is dispensed.
- c. A patient has an allergic reaction to a penicillin.
- d. A patient develops hyperkalemia from an ACE inhibitor.
Answer: b. A pharmacist catches that the dose of vancomycin is too high for the patient’s renal function before it is dispensed.
43. A pharmacist’s failure to counsel a patient on the signs of digoxin toxicity in the setting of CKD could be considered an error of:
- a. Omission
- b. Commission
- c. Dispensing
- d. Prescribing
Answer: a. Omission
44. Polypharmacy increases the risk of medication errors in CKD patients because:
- a. There are more opportunities for dosing errors.
- b. There is a higher chance of drug-drug interactions.
- c. It can lead to decreased adherence.
- d. All of the above.
Answer: d. All of the above.
45. Which of the following is a key safety practice for a pharmacist?
- a. Assuming the prescriber is always correct.
- b. Verifying a patient’s renal function before dispensing any new renally-cleared medication.
- c. Relying solely on computer alerts.
- d. Avoiding communication with the patient.
Answer: b. Verifying a patient’s renal function before dispensing any new renally-cleared medication.
46. Which antibiotic does NOT require dose adjustment in renal impairment?
- a. Ciprofloxacin
- b. Vancomycin
- c. Ceftriaxone
- d. Gentamicin
Answer: c. Ceftriaxone
47. A “Root Cause Analysis” is performed after an error to:
- a. Determine who to blame.
- b. Identify the underlying systems-based factors that contributed to the error.
- c. Complete the necessary paperwork.
- d. Calculate the financial impact of the error.
Answer: b. Identify the underlying systems-based factors that contributed to the error.
48. An active learning session on medication errors is part of which course?
- a. PHA5162L Professional Practice Skills Lab II
- b. PHA5104 Sterile Compounding
- c. PHA5781 Patient Care I
- d. PHA5007 Population Health
Answer: a. PHA5162L Professional Practice Skills Lab II
49. The most effective way to prevent medication errors in any population, including CKD, is through:
- a. A culture of safety and redundant system checks.
- b. Increased individual punishment.
- c. Less communication between healthcare professionals.
- d. Faster dispensing times.
Answer: a. A culture of safety and redundant system checks.
50. The ultimate reason to study medication errors in CKD is to:
- a. Pass the final exam.
- b. Fulfill a course objective.
- c. Develop the skills and vigilance necessary to protect a vulnerable patient population from preventable harm.
- d. Learn how to override computer alerts more efficiently.
Answer: c. Develop the skills and vigilance necessary to protect a vulnerable patient population from preventable harm.