Patient Safety and Quality Assurance Study Guide for the PTCB Exam

General Information

Your knowledge of Patient Safety and Quality Assurance concepts covered in this study guide will be assessed by about 23.75% of the questions on the newest version of the Pharmacy Technician Certification Board (PTCB) exam. This percentage is about 3% less than the 2020 exam.

Potential for Risk

When working as a pharmacy technician, there is always a risk of a medication error occurring. There are numerous steps in place to help mitigate and reduce the potential for risk. Being mindful and aware of these strategies will help you perform your daily tasks in the pharmacy more efficiently and without errors.

High-Alert/Risk Medications

High-alert and high-risk medications are those medications that are more likely to cause significant patient harm if used incorrectly or in error. While the rate of errors with these drugs might not be higher than others, the consequences of those errors are much more severe. The Institute for Safe Medication Practices (ISMP)is the primary resource for identifying high-alert medications in both community and hospital settings. To mitigate risk, pharmacies often use “Redundant Checks,” such as requiring a second signature or a “Double-Check” by another staff member before these drugs are dispensed or administered.

Key ISMP High-Alert Categories to Know:

• Anticoagulants: (e.g., Warfarin, Heparin, Enoxaparin) – Risk of severe bleeding.

• Insulins: (All types, including U-500) – Risk of fatal hypoglycemia.

• Opioids/Narcotics: (e.g., Fentanyl, Hydromorphone, Morphine) – Risk of respiratory depression.

• Injectable Potassium Chloride/Electrolytes: – Risk of cardiac arrest if administered incorrectly.

• Chemotherapy Agents: (e.g., Methotrexate) – High toxicity.

• Neuromuscular Blocking Agents: (e.g., Succinylcholine) – Can cause respiratory paralysis if given to the wrong patient.

Look-Alike/Sound-Alike (LASA) Medications

Similar medications are a serious safety concern and a common cause of medication errors. Just because the names of two medications look or sound alike does not mean they can be used interchangeably. Moreover, errors in communication or drug selection can have potentially fatal consequences.

These errors often occur due to “Confirmation Bias.” This is a psychological phenomenon where a person “sees” what they expect to see. For example, if a technician is used to pulling Hydralazine, they may look at a bottle of Hydroxyzine and mentally confirm it is the correct drug because the labels look similar.

For drugs that look like other drugs, pharmacy technicians should always double-check the drug name and strength. Tall man lettering is used on many drug products and implemented in many pharmacy systems to help pharmacy personnel differentiate two very similar-looking medication names. Please refer to the “Tall Man Lettering” subsection below for more information on that concept.

As is the case with look-alike drugs, pharmacy technicians should always double-check the drug name and strength of sound-alike drugs. Again, tall man lettering may be used when communicating in writing. Simply asking the person speaking to spell the drug name can help clarify that the correct drug is being discussed.

Error Prevention Strategies

“Everybody makes mistakes.”

You’ve heard this before, and it’s certainly true, even in a pharmacy. However, when dealing with people’s health, a mistake can be extremely dangerous, so the goal of any good pharmacy worker should be to identify and acknowledge errors and reduce their occurrence. The best way to deal with medication errors is to prevent them from occurring in the first place. Many practices can be implemented to reduce the chances of a medication error and, if one does occur, to reduce the likelihood that it will affect the patient. Modern pharmacy safety relies on Continuous Quality Improvement (CQI), which is a systematic process of identifying, documenting, and analyzing errors to prevent them from happening again.

Effective error prevention requires a “Just Culture” or “Non-Punitive” environment. This means that staff are encouraged to report “near misses” and errors without the fear of immediate punishment. The focus is on finding the “Root Cause”—the systemic reason the error happened—rather than simply blaming an individual.

Correct Order to Correct Patient

It is important to remember the five “rights” of medication administration: right drug, right dose, right time, right route, and right patient. Remembering these five rights will help prevent a medication error from occurring. When ringing up a customer at the register or drive-thru, it is easy to grab the wrong order and dispense it to the wrong patient, as retail pharmacies can be a fast-paced environment.

In addition to staying vigilant, performing these strategies will help get the correct order to the correct patient every time:

• Verify the name and date of birth.

• Verify the street address.

• Briefly mention what you have for the patient to pick up, like “I have your blood pressure and heartburn medication here. Was there anything else you were looking for?”

These three simple verification steps will help reduce the risk of a dispensing error.

Tall Man Lettering

Tall man lettering is used to help differentiate portions of sound-alike/look-alike drug names by drawing one’s eye to a potential source of error and preventing “selection errors” during the filling process. Consider the example of hydralazine (an antihypertensive) and hydroxyzine (an antihistamine). These drugs look the same except for the middle three letters, but mixing them up could be very dangerous. Therefore, on the bottle and when communicating the drug name in writing, those three letters in each name will be capitalized to draw the reader’s eye to the potential discrepancy: hydrALAzine and hydrOXYzine.

The list of approved tall man lettering is officially maintained and recommended by the FDA and the ISMP. Most pharmacy computer systems automatically populate these names, but technicians must remain vigilant to use this capitalization when hand-writing labels or compounding logs to maintain the standard of safety.

Inventory Management

Inventory management accounts for a significant portion of a pharmacy team’s workload. This process may include ordering and receiving products, identifying specific storage requirements, and removing expired or recalled medications. Schedule 2 (C-II) controlled substances are subject to additional inventory checks and balances. Within a pharmacy, different strategies to separate medications may be employed. For example, high-risk medications may be stored separately from other medications, and/or medications with similar formulations may be stored together so the pharmacy employee can compare “like” products to identify the correct drug.

Leading and Trailing Zeros

Leading and trailing zeros are an important concept for a pharmacy technician to understand, especially during data entry and when performing calculations. For whole numbers, do not use trailing zeros. For instance, you should not write 5.0, which could be mistaken for 50. Instead, simply write the whole number (5) and add the necessary unit.

On the other hand, a leading zero should be added before a decimal point (as in the case of 0.5 mg or 0.75 mL) to minimize the risk of overdose.

Barcodes

Similar to a National Drug Code (NDC) identifier, each drug’s barcode is unique and can be used to verify that the correct product is chosen. It is impossible to do this with the naked eye. Instead, a scanner may be used to scan the individual drug product into the system and to verify the correct drug is chosen in the filling process.

Abbreviation Use

Abbreviations should be avoided whenever possible. For example, QD should be written out as “once a day” or “daily” to avoid confusion with QID (four times a day) or QOD (every other day). In the busy work environment, abbreviations may seem faster or easier to use, but spelling out what you mean will save time and prevent errors in the long run.