Practice Management>Quality Improvement Practice Test

A community pharmacy notes three near-misses in two weeks involving hydroxyzine 25 mg and hydralazine 25 mg. Each incident occurred during evening rush hours when staffing was lean and the drugs were stocked adjacent on the same shelf. A technician selected hydralazine instead of hydroxyzine, but the pharmacist caught the error at final check. In another case, the wrong drug reached the will-call bin before discovery. Review of quality logs shows similar look-alike/sound-alike (LASA) mix-ups in the past year. The pharmacy uses manual NDC checks and relies on staff to initial labels but does not use barcode verification. Leadership wants to reduce the risk of a serious event while maintaining throughput.

In a busy community pharmacy, three near-miss incidents in the past month involved dispensing the wrong strength of lisinopril (10 mg instead of 20 mg, and vice versa). The pharmacy shelves multiple strengths side by side, with small-print manufacturer labels, and there is no barcode scanning in the filling or verification workflow. Technicians select stock bottles and enter NDCs manually, and pharmacists visually verify during peak evening hours. A new technician reports that similar-appearing bottles and hurried workflow make it easy to grab the wrong strength. The pharmacy manager reviewed incident reports and confirmed a trend with ACE inhibitors and beta-blockers. No patients were harmed, but leadership wants a sustainable fix that decreases selection errors across all look-alike medications without slowing operations dramatically.