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tech talk ce
THE NATIONAL CONTINUING EDUCATION PROGRAM FOR PHARMACY TECHNICIANS 1 CE Unit FREE
ANSWER ONLINE FOR INSTANT RESULTS AT WWW.CANADIANHEALTHCARENETWORK.CA OCTOBER 2018

APPROVED FOR



A
1 CE Unit
pproved for 1 CE unit by
How to prevent
medication incidents
the Canadian Council on
Continuing Education in
Pharmacy. File no. 1329-2018-
2562-I-T. Please consult this
course online at eCortex.ca
for expiry dates. by Certina Ho, RPh, BScPhm, MISt, MEd, PhD and
Adrian Boucher, B.Sc. (Hon.), PharmD, RPh

Answer this CE online for instant


results and accreditation. Visit
www.CanadianHealthcareNetwork.ca

CE JUST FOR TECHNICIANS


Tech Talk CE is the only national
continuing education program for
Canadian pharmacy technicians.
As the role of the technician expands,
use Tech Talk CE as a regular part of
your learning portfolio. Note that a
passing grade of 70% is required to
earn the CE credit.
Tech Talk CE is generously sponsored
by Teva. Download back issues at
www.CanadianHealthcareNetwork.ca.
The author has no competing interests
to declare.

INSTRUCTIONS
1. After carefully reading this lesson,
study each question and select the one
answer you believe to be correct.
2.Answer the test online at eCortex.ca.
To pass, a grade of at least 70% (11 out
of 15) is required. 
Learning objectives
3. Complete the required feedback for Upon successful completion of this lesson, you will be able to do the following:
this lesson online at eCortex.ca. 1. Understand the role of the pharmacy technician in the identification and prevention of
medication incidents.
CE FACULTY 2. Recognize how human and environmental factors contribute to medication incidents.
CE Coordinator: 3. Apply system-based approaches to prevent medication incidents in the future.
Rosalind Stefanac
Clinical Editor: Introduction and why incidents occur is necessary to pre-
Lu-Ann Murdoch, BScPhm
Pharmacy technicians are an integral part of vent the potentially devastating effects they
Authors:
Certina Ho, RPh, BScPhm, MISt, delivering pharmaceutical care in community, can have on patients and the healthcare sys-
MEd, PhD and Adrian Boucher, hospital, and long-term care settings. tem as a whole. As such, this lesson reviews
B.Sc. (Hon.), PharmD, RPh Increasingly, pharmacy technicians are some of the most common types of medica-
involved in quality assurance initiatives to tion incidents that pharmacy technicians may
identify and implement measures to prevent encounter and presents system-based strat-
medication incidents. Understanding how egies to prevent recurrence. Medication

An educational service for Canadian pharmacy technicians,


brought to you by Teva.

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FIGURE 1 - Designing Effective Strategies to Prevent Medication Incidents Using the Hierarchy of Effectiveness[2]

Le
e
ibl

ss

Human-based Strategies
as

Ef
Forcing Functions

Fe
System-based Strategies

fec
& Constraints
ss

tiv
Le

e/
e/

Mo
tiv

re
fec

Automation & Computerization

Fea
Ef

sib
re
Mo

le
Drug Protocols, Standardization & Simplification

Reminders, Checklists & Independent Double Checks

Rules & Policies

Education & Information

incidents are defined as any preventable pendent double checks. These aim to mation bias exists whenever an individual
events that may cause or lead to inappropri- change the system but are generally less completes any type of medication-use
ate medication use or patient harm while the effective as they rely to varying degrees on activity (Table 1). Confirmation bias leads
medication is in the control of the healthcare human memory and surveillance. Finally, individuals to “see” information that confirms
professional, patient, or consumer.[1] Readers at the bottom of the hierarchy are human- their expectations, rather than information
are encouraged to obtain additional informa- based interventions such as rules and poli- that contradicts their expectations.[3]
tion about this topic from the Institute for Safe cies, and education and information (e.g.
Medication Practices Canada (ISMP Canada) staff training and meetings). These focus 1. Order Entry
website at www.ismp-canada.org. on changing individual behaviours and are Pharmacy technicians are most frequently
often times more feasible and cost-effective involved in entering medication orders into
Strategies to Prevent Medication to implement than system-based interven- the computer system. Below are some
Incidents tions. Although all the strategies can play a examples of medication incidents that are
Following identification and review of a role in the prevention of errors, when possi- commonly associated with the order entry
medication incident, it is often necessary ble, choose high-leverage tools designed stage of the medication-use process.
to develop risk mitigation strategies. The to fix systems and utilize lower-leverage
Hierarchy of Effectiveness organizes types interventions to support their implementa- A. Look-alike/Sound-alike
of interventions according to their ability to tion (Figure 1). Medication Names
prevent incident recurrence (Figure 1).[2] Bisoprolol 5 mg was ordered by the physi-
Items at the top of the hierarchy are power- MEDICATION-USE PROCESS cian for a long-term care home resident, but
ful, high-leverage strategies that focus on Pharmacy technicians can be involved in all the prescription was entered as Bisacodyl 5
changing systematic factors that contrib- stages of the medication-use process; mg. However, the prescription was filled
uted to the incident. These include forcing however, order entry, and preparation and with Bisoprolol 5 mg tablets (i.e. the correct
functions and constraints (e.g. elimination dispensing are the most commonly per- medication), but incorrectly labelled as
of a high-risk medication from the formu- formed tasks. Therefore, it is important for Bisacodyl 5 mg.[4]
lary), and automation and computerization pharmacy technicians to be familiar with As more medications are introduced into
(e.g. barcoding). Moderate-leverage strate- and be able to identify, report, and prevent the market, the risk of incidents associated
gies are those that combine qualities from medication incidents in these two stages of with look-alike, sound-alike medications will
both system-based and human-based the medication-use process. Readers continue to increase. A common contribut-
interventions such as standardization and should be vigilant and aware that both ing factor is confirmation bias.[3] The use of
simplification (e.g. use of pre-printed order human and environmental factors can con- TALLman lettering, which consists of apply-
sets) and reminders, checklists, and inde- tribute to medication incidents, and confir- ing uppercase lettering to certain parts of

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with urinary tract infection (UTI) by her family


TABLE 1 - Contribution of human and environmental factors to
medication incidents physician. She presented a new prescription
with Trimethoprim / Sulfamethoxazole (TMP/
Common Contributing Factors to Medication Incidents SMX) DS and on her medication profile at
Environmental Factors Look-alike/Sound-alike Medication Names the pharmacy, it was shown that she was
currently taking Ramipril for her high blood
Look-alike Labelling/Packaging of Medications
pressure. The potential drug-drug interac-
Dangerous Abbreviations, Symbols, and Dose tion (DDI) between TMP/SMX and Ramipril
Designations was flagged by the dispensing software
Workload and Interruptions during order entry, but the alert was ignored
and bypassed by the pharmacy technician.
Human Factors Alert Fatigue
The DDI, which may lead to hyperkalemia,
Confirmation Bias was then caught and intercepted by the
pharmacist during clinical verification of the
the medication name, is one strategy to dif- Potassium Chloride 40 mEq po q4h was prescription.
ferentiate medications.[5] Pharmaceutical then administered to the patient for the next The increasing number of medications in
manufacturers and vendors of pharmacy two weeks. The patient was later re-admit- the market makes it challenging for health-
practice management systems are encour- ted to the hospital with hyperkalemia, dehy- care practitioners to keep up with new infor-
aged to implement TALLman lettering on dration, and acute renal failure. The “D/C” mation and new DDIs. In addition, the vast
packaging and computerized drop-down abbreviation on the prescription order was number of clinically insignificant alerts pre-
menu for look-alike, sound-alike medica- misinterpreted by the long-term care health- sented by computerized drug interaction
tions in Canada (i.e. automation and com- care practitioners as “discharge” instead of detection systems often leads to alert
puterization). Readers are encouraged to “discontinued”.[7] fatigue in pharmacy professionals, increas-
learn more about TALLman lettering from The use of some abbreviations, symbols, ing the risk of clinically significant DDIs being
the Institute for Safe Medication Practices and dose designations has been identified missed.[9] The use of computerized drug
Canada (ISMP Canada) website at https:// as an underlying cause of serious, even fatal interaction detection systems, although not
www.ismp-canada.org/download/ medication errors. ISMP Canada’s “Do Not entirely perfect, is still more effective than
TALLman/TALLman_lettering.pdf. Use” list of abbreviations, symbols, and relying on human memory to detect drug
At the pharmacy level, the following strat- dose designations is helpful for preventing interactions (i.e. automation and computeri-
egies may be considered to prevent inci- errors associated with commonly misinter- zation). Complementary strategies include
dents associated with look-alike/sound-alike preted prescriptions.[8] Ideally, healthcare 1) an internal policy to adopt a standardized
medication names: 1) perform independent providers should aim to eliminate the use of approach for handling DDIs (e.g. verify with
double checks of each other’s work at each dangerous abbreviations, symbols and dose the pharmacist when alerted to a DDI during
step of the workflow whenever possible (e.g. designations at the prescribing stage (i.e. order entry) (i.e. rules and policies); and
verify all verbal orders by repeating it back forcing functions and constraints) through 2) continuous professional development
or spelling out the drug names) (i.e. remind- the use of computerized physician order and staff training related to clinically signifi-
ers, checklists, and independent double entry (CPOE) and e-prescribing. In order to cant DDIs (i.e. education and information).[10]
checks); and 2) include look-alike, sound- intercept and capture potential incidents at
alike medication education as part of staff the order entry stage, pharmacy technicians 2. Preparation and Dispensing
training and continuous professional devel- can 1) perform independent double checks Pharmacy technicians are responsible for the
opment (i.e. education and information).[6] of each other’s work (e.g. verify order entry majority of the preparation and dispensing of
with another pharmacy professional in the medications. In this section, we will illustrate
B. Dangerous Abbreviations team when interpreting hand-written pre- some of the most common medication inci-
A long-term care home resident was admit- scriptions) (i.e. reminders, checklists, and dent examples that may occur during pre-
ted to the hospital for treatment of dehydra- independent double checks); and 2) keep scription preparation and dispensing, and
tion. While in hospital, the patient was pre- abreast of the latest information on the “Do discuss potential interventions to help pre-
scribed Potassium Chloride 40 mEq with Not Use: Dangerous Abbreviations, vent these incidents from happening again.
two doses to be administered four hours Symbols and Dose Designations” list (i.e.
apart. This prescription order was noted education and information) from the Institute A. Look-alike Labelling/Packaging of
with “D/C”, which was intended to be inter- for Safe Medication Practices Canada (ISMP Medications
preted as “discontinued” at the hospital after Canada) website at https://www.ismp-can- A patient with insulin-dependent diabetes
the two doses. The patient was discharged ada.org/download/ISMPC_List_of_ mellitus had a prescription for insulin car-
back to the long-term care home the next Dangerous_Abbreviations.pdf. tridges. The patient had recently obtained a
day and “Potassium Chloride 40 mEq po refill of the prescription from the community
q4h D/C” was included in the prescription C. Drug-Drug Interactions pharmacy, which consisted of several boxes
orders at the long-term care home. A 70-year-old female patient was diagnosed of 5 cartridges each. On the morning of the

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incident, the patient had inserted a new car- Compounded products are prepared cated medication regimes, changes to a
tridge from one of the new boxes into an when patients require a medication in a patient’s medication therapy between
insulin pen. A short time after self-injecting dose or dosage form that is not commer- packs, and frequent use of halved or quar-
the prescribed morning dose, the patient cially available. Both sterile and non-sterile tered tablets can still contribute to incidents
was found in a diaphoretic state, with pupils compounding are complex, high-risk pro- with this process. Potential interventions to
dilated and a decreased level of conscious- cesses that require knowledge and skills to reduce the associated risks include:
ness. It was discovered that, along with perform safely. The National Association of 1) conducting an independent double check
several boxes of the correct insulin car- Pharmacy Regulatory Authorities (NAPRA) before a compliance pack is sealed (i.e.
tridges containing 30% short-acting insulin has prepared three model standards for reminders, checklists, and independent
and 70% intermediate-acting insulin, one pharmacy compounding: 1) non-hazardous double check); 2) having a dedicated space
box of ultrashort-acting insulin cartridges sterile preparations; 2) hazardous sterile and tools to prepare compliance packs
had been dispensed.[11] preparations; and 3) non-sterile prepara- (i.e. rules and policies); and 3) regularly
The label and packaging of a drug tions.[15] Distractions or interruptions during conducting comprehensive medication
communicate key information about preparation, complex dosing calculations, reviews, including simplification of medica-
appropriate medication use and aid in and use of different dosing units (e.g. mg vs. tion regimes whenever possible, for patients
product identification and selection. Health mcg) can contribute to errors when com- (i.e. education and information).[18]
Canada has developed practice guidelines pounding. Strategies to improve the safety
for packaging and labelling of prescription of compounding include: 1) developing stan- Conclusion
drugs in order to develop safer packages.[12] dardized guidelines and documentation The medication-use system is complex and
Prevention of these incidents is particularly worksheets for preparation of each com- presents many opportunities for medication
important for incidents involving “high-alert” pounding product (i.e. simplification and incidents, particularly during order entry, and
medications, such as insulin, as they are standardization); 2) using independent verifi- preparation and dispensing (Table 1). As part
more likely to cause patient harm.[13] Readers cation at each step of preparation, including of the healthcare team, pharmacy technicians
are encouraged to learn more about the measurement of ingredients (i.e. reminders, can play a significant role in reporting and
ISMP List of High-Alert Medications in checklists, and independent double checks); preventing medication incidents and their
Community/Ambulatory Healthcare from the and 3) offering continuous professional associated harms. Reporting of medication
ISMP website at https://www.ismp.org/sites/ development and training to ensure staff incidents and near misses is important for
default/files/attachments/2017-11/highAlert- competency in compounding (i.e. education analysis and shared learning in order to miti-
community.pdf. and information).[16] gate risk in the future. Through identification
At the pharmacy level, strategies to help and reporting of medication incidents, and
prevent incidents associated with medica- C. Multi-Medication Compliance Aids participation in the development of system-
tions with look-alike labelling/packaging A pharmacy technician at a community based interventions (Figure 1), pharmacy
include 1) ordering from different manufac- pharmacy prepared a compliance pack for a technicians have the opportunity to help
turers for similar looking medications (i.e. patient. During preparation, two tablets of improve the safety of the healthcare system.
forcing functions and constraints); 2) imple- methotrexate 2.5 mg was placed in a blister
menting a barcoding system to ensure the compartment for every day of the week, REFERENCES
1. Definitions of Terms. ISMP Canada. Available from:
correct selection of medications (i.e. auto- rather than once weekly. The pharmacist https://www.ismp-canada.org/definitions.htm
mation and computerization); 3) segregating discovered the error and asked the phar- 2. Grissinger M. Medication error-prevention “toolbox.”
P&T 2003;28(5):298.
similar-looking medications from each other macy technician to remove the extra tablets 3. Human Factors and Substitution Errors. ISMP Canada
by installing physical dividers or using bas- from the compliance packages. The phar- Safety Bulletin 2003; 3(5): 1-2.
4. Concerned Reporting: Mix-ups Between Bisoprolol
kets in the storage area (i.e. simplification macy technician only removed one 2.5 mg and Bisacodyl. ISMP Canada Safety Bulletin 2012; 12(9):
and standardization); and 4) scanning every tablet from each day of each week. The 1-6.
5. Application of TALLman Lettering for Selected High-
package or inventory bottle during prepara- compliance packages were not re-checked Alert Drugs in Canada. ISMP Canada Safety Bulletin
tion and dispensing (i.e. rules and policies).[6] prior to dispensing to the patient. Three 2015; 15(10): 1-6.
6. Kawano A, Li QK, Ho C. Preventable Medication
weeks later, the patient was admitted to the Errors – Look-alike/Sound-alike Drug Names. Pharmacy
B. Compounding hospital with a severe infection.[17] Connection 2014; Spring: 28-33.
7. Medication Reconciliation and Medication Review:
A pharmacy technician working in a commu- Increasing medication use and an aging Complementary Processes for Medication Safety in Long-
nity pharmacy used clonidine powder to population have prompted greater use of Term Care. ISMP Canada Safety Bulletin 2007; 7(9): 1-3.
8. Reaffirming the “Do Not Use: Dangerous
prepare a suspension for pediatric use. The multi-medication compliance aids (i.e. com- Abbreviations, Symbols and Dose Designations” List.
prescription required 25 mcg (0.025 mg) of pliance or blister packs) to help patients ISMP Canada Safety Bulletin 2018; 18(4): 1-6.
9. Reducing Adverse Events and Hospitalizations
clonidine, but the technician added 25 mg. manage their medications. Due to the com- Associated with Drug Interactions. ISMP Canada Safety
The error was missed by the pharmacist plexity associated with their preparation, Bulletin 2013; 13(3): 1-3.
10. Aggregate Analysis of Medication Incidents Involving
during the final prescription check. The sus- they may confer an increased risk of inci- Drug Interactions. ISMP Canada Safety Bulletin 2012;
pension was administered to the child, who dents compared to traditional dispensing. 12(5): 1-4.
11. Patient Report of Insulin Mix-Up Shared. ISMP
was later admitted to the hospital for severe The recent growth of automated packaging Canada Safety Bulletin 2007; 7(6): 1-2.
hypotension.[14] may help mitigate this. However, compli- 12. Good Label and Package Practices Guide for

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Prescription Drugs. Ottawa, ON: Health Canada, June Bulletin 2011; 11(1): 1-3. Spring: 28-32.
2016. 15. Guidance Document for Pharmacy Compounding 17. Incidents of Inadvertent Daily Administration of
13. ISMP List of High-Alert Medications in Community/ of Non-sterile Preparations – Companion to the Model Methotrexate. ISMP Canada Safety Bulletin 2008; 8(2):
Ambulatory Healthcare. ISMP 2011. Available Standards for Pharmacy Compounding of Non-sterile 1-3.
from: https://www.ismp.org/sites/default/files/ Preparations. Ottawa, ON: National Association of 18. Tsang J, Ho C. Complexity and Vulnerability of
attachments/2017-11/highAlert-community.pdf Pharmacy Regulatory Authorities (NAPRA), June 2018. Compliance Pack Preparation: A Multi-Incident Analysis
14. Oral Clonidine Suspension: 1000-Fold Compounding 16. Kawano A, Ho C. Quality and Safety in Compounding by ISMP Canada. Pharmacy Connection 2014; Winter:
Errors Cause Harm to Children. ISMP Canada Safety Non-Sterile Preparations. Pharmacy Connection 2012; 32-37.

QUESTIONS Please select the best answer for each question and answer online
at eCortex.ca for instant results.

1. Which of the following statements is tions from each other by installing physical a) Clonidine b) Insulin
FALSE with respect to the Hierarchy of dividers in the storage area. c) Warfarin d) Methotrexate
Effectiveness. c) Set up an internal policy that requires an
a) Interventions involving reminders, check- independent double check be performed 8. H ydroxyzine 50 mg was ordered by the
lists and independent double checks are by another pharmacy professional for all physician, but the prescription was
more effective than rules and policies. dispensing activities. entered as Hydroxyurea 500 mg. The
b) Interventions involving automation and d) Install a bar-coding technology into the MOST effective intervention to prevent this
computerization are more effective than dispensing workstations so that, in addition incident from happening is:
standardization and simplification. to visual checking of the Drug Identification a) Host a staff meeting and educate the
c) Interventions involving education and infor- Number (DIN) during dispensing, scanning pharmacy team on common look-alike/
mation are more feasible than rules and of the bar-code on the inventory drug sound-alike medications.
policies. product may also serve as an independent b) Post the list of look-alike/sound-alike drug
d) Interventions involving automation and double check. names with recommended TALLman let-
computerization are more feasible than tering at each pharmacy computer work-
rules and policies. 4. T he following contributing factors could be station.
involved in a medication incident involving c) Install TALLman lettering in the drop-down
2. Which of the following solutions would be the mix-up of diphenhydramine and menu of the pharmacy computer system.
the LEAST effective in preventing drug dimenhydrinate. d) Perform independent double checks at
name confusion due to look-alike/sound- a) Look-alike/sound-alike medication names each step of the pharmacy workflow.
alike drug names? b) Workload or interruptions
a) Organize an information session to edu- c) Confirmation bias 9. T hroughout the medication-use process
cate pharmacy staff members about vari- d) All of the above (e.g. prescribing, order entry, preparation
ous pairs of look-alike/sound-alike drugs. and dispensing, and administration),
b) Segregate look-alike/sound-alike medica- 5. A
 ccording to the ISMP Canada’s “Do Not levothyroxine doses may be expressed in
tions from each other by installing physical Use” list of abbreviations, symbols, and micrograms (mcg) or in milligrams (mg).
dividers in the storage area. dose designations, the following have Dose conversion from milligrams (mg) to
c) Set up an internal policy that requires an been reported as being frequently micrograms (mcg), or vice versa, may
independent double check be performed misinterpreted and involved in harmful result in medication errors or near misses.
by another pharmacy professional for all medication errors, EXCEPT: The BEST possible strategy to prevent this
dispensing activities. a) OD error from happening in a hospital setting
d) Install a bar-coding technology into the b) D/C is to:
dispensing workstations so that, in addition c) HS a) Restrict the number of strengths of
to visual checking of the Drug Identification d) Lack of leading zero (e.g. .5 mg) levothyroxine to be kept in the hospital
Number (DIN) during dispensing, scanning pharmacy inventory.
of the bar-code on the inventory drug 6. T
 he list of look-alike/sound-alike drug b) Express levothyroxine doses consistently
product may also serve as an independent names with recommended TALLman let- in micrograms (mcg), not milligrams (mg),
double check. tering in Canada includes the following, in all written or computer-generated pre-
EXCEPT: scriptions and health records, pharmacy
3. Which of the following solutions is the a) dimenhyDRINATE / diphenhydrAMINE systems, medication administration
LEAST feasible to implement in a short b) clomiPRAMINE / clomiPHENE records, and patient education materials
period of time (e.g. 1 to 3 months) to pre- c) vinBLAStine / vinCRIStine at the hospital.
vent incidents associated with look-alike/ d) HYDROmorphone / morphine c) Educate the medical, pharmacy, and
sound-alike drug names? nursing staff on common dose conversion
a) Organize an information session to 7. A
 ccording to the ISMP list of high-alert errors associated with levothyroxine.
educate pharmacy staff members about medications in community/ambulatory d) Perform independent double checks at
various pairs of look-alike/sound-alike healthcare, the following medications are each step of the medication-use process
drugs. associated with a higher risk of patient at the hospital.
b) Segregate look-alike/sound-alike medica- harm when they are used in error, EXCEPT:

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10. The vast number of clinically insignificant a) Scan every package or vial during Canada (ISMP Canada)
alerts presented by computerized drug preparation and dispensing, and b) The National Association of Pharmacy
interaction detection systems often leads administration. Regulatory Authorities (NAPRA)
to alert fatigue in pharmacy professionals. b) Segregate these two products from each c) Health Canada
Pharmacy technicians can play a signifi- other by using baskets in the pharmacy d) World Health Organization (WHO)
cant role in intercepting and preventing inventory area and the patient care area at
clinically significant drug-drug interac- the nursing station. 14. P reparation of multi-medication
tions by: c) Order one of the products from a different compliance aids is associated with an
a) Verifying with the pharmacist when manufacturer. increased risk of incidents compared to
overriding a drug-drug interaction alert d) Organize an in-service for both pharmacy traditional dispensing. This is typically
b) Attending continuous professional and nursing staff to share this information NOT due to:
development and education sessions to widely. a) Workload or distractions
keep updated on clinically significant drug- b) Unanticipated changes to patient’s
drug interactions 12. W hich organization has developed medication therapy
c) Communicating with the patient during practice guidelines for manufacturers to c) Frequent use of halved or quartered tablets
order entry to make sure patient’s follow regarding safe packaging and during preparation
medication profile is up-to-date labelling of prescription drugs? d) Complicated medication regimes of
d) All of the above a) The Institute for Safe Medication Practices patient’s therapy
Canada (ISMP Canada)
11. Look-alike labelling and packaging of b) The National Association of Pharmacy 15. P  harmacy technicians have the
parenteral diphenhydramine 50 mg/mL Regulatory Authorities (NAPRA) opportunity to help improve safety of the
and phenylephrine 10 mg/mL products c) Health Canada healthcare system by:
manufactured by the same pharmaceuti- d) World Health Organization (WHO) a) Reporting medication incidents
cal company was identified as posing a b) Analyzing contributing factors of
risk of mix-up between these two medi- 13. T he Model Standards for Pharmacy medication incidents
cations by pharmacy and nursing staff at Compounding of Non-sterile Preparations c) Developing system-based error-prevention
the hospital. What SHOULD be done was developed and published by: interventions
immediately? a) The Institute for Safe Medication Practices d) All of the above

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How to prevent medication incidents
1 CE Unit • OCTOBER 2018 1.  a b c d 4.  a b c d 7.  a b c d 10.  a b c d 13.  a b c d
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