PEBC MCQ Ethics, Patient Safety & Quality question: technician selected hydroxyzine instead of hydralazine

PEBC MCQEthics, Patient Safety & Quality

After a near miss in which a technician selected hydroxyzine instead of hydralazine, the pharmacy manager wants to respond in a way that improves safety. Which approach best reflects a just culture?

a. Keep the event confidential and avoid reporting near misses
b. Require the technician to work slower on every prescription
c. Suspend the technician to show that errors will not be tolerated in future
d. Analyse system factors such as shelf placement and look-alike names

Show the answer and explanation

Answer: d. Analyse system factors such as shelf placement and look-alike names

A just culture treats most errors as products of system weaknesses, encourages reporting of incidents and near misses without blame for honest mistakes, and holds individuals accountable only for reckless behaviour. Here, look-alike/sound-alike names and adjacent storage are system issues; fixes include separating the products, tall man lettering and barcode scanning. Punishment or secrecy discourages reporting. Source: ISMP Canada, Medication incidents and just culture resources; ISMP Canada, Look-alike/sound-alike drug names and tall man lettering (2023); NAPRA Model Standards for Continuous Quality Improvement and Medication Incident Reporting (2021).

Common mistake

Blaming individuals for errors driven by system design.

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