PTCE Patient Safety Practice Test

25 practice questions

Choose an answer, then check it under Show answer.

1. Question 1 of 25Medium

   A patient reports experiencing a severe, unexpected adverse reaction to a recently approved prescription drug. The reaction required hospitalization. The pharmacy technician is documenting the event. Which action is most appropriate?

   1. AA. Record the event only in the patient's medication profile for future reference.
   2. BB. Contact the drug manufacturer directly and ask them to investigate.
   3. CC. Wait for the pharmacist to decide whether to report, as technicians cannot initiate reports.
   4. DD. Assist the pharmacist in submitting a report to the FDA MedWatch program.
   Show answer to question 1

   Answer: D. Assist the pharmacist in submitting a report to the FDA MedWatch program.

   Serious adverse events (e.g., hospitalization, life-threatening reaction) should be reported to the FDA via MedWatch. Pharmacy technicians can assist in gathering information and completing the report under pharmacist supervision. Prompt reporting helps identify safety issues with new drugs.

   Why the other options are wrong

   • AInternal documentation alone does not fulfill the requirement to report serious adverse events to the FDA; MedWatch is the official system.
   • BManufacturers are required to report to FDA, but the pharmacy should also report directly to ensure timely and accurate information.
   • CTechnicians can participate in the reporting process; they should not simply wait if the pharmacist is busy, but rather bring it to the pharmacist's attention and assist.

2. Question 2 of 25Medium

   Which of the following is a recommended strategy to prevent errors with look-alike, sound-alike (LASA) medications?

   1. AA. Keep LASA drugs in the same bin to facilitate comparison
   2. BB. Rely solely on pharmacist verification to catch errors
   3. CC. Use tall man lettering on labels, bins, and computer screens
   4. DD. Store LASA drugs alphabetically on the same shelf
   Show answer to question 2

   Answer: C. Use tall man lettering on labels, bins, and computer screens

   Tall man lettering, as in DOBUTamine and DOPamine, highlights the letters that differ between look-alike names and is a core ISMP strategy for LASA drugs. It works best alongside physical separation of the products and independent checks, not in place of them.

   Why the other options are wrong

   • AKeeping them together makes it easier to pick the wrong drug; they should be separated.
   • BPharmacist verification is important but should be combined with other strategies like tall man lettering and separation.
   • DAlphabetical storage on the same shelf increases the risk of grabbing the wrong bottle; separation is preferred.

3. Question 3 of 25Easy

   A prescriber writes an order for "ciprofloxacin otic, 4 drops AD bid." Why does the Institute for Safe Medication Practices (ISMP) recommend avoiding the abbreviation "AD"?

   1. AA. It can be misinterpreted as "OD," leading to administration in the eye
   2. BB. It can be confused with "alternating days," resulting in an incorrect dosing interval
   3. CC. It can be mistaken for "after dinner," causing improper administration timing
   4. DD. It can be misinterpreted as "AS," leading to administration in the left ear
   Show answer to question 3

   Answer: A. It can be misinterpreted as "OD," leading to administration in the eye

   The abbreviation "AD" (right ear) is frequently misread as "OD" (right eye), which can cause an otic preparation to be erroneously instilled into the eye. Although confusing "AD" with "AS" (left ear) can occur, the primary safety concern highlighted by ISMP is cross-route administration errors between the ear and eye.

4. Question 4 of 25Medium

   A pharmacy technician notices a near-miss error where a patient almost received the wrong medication. Which organization maintains a voluntary, confidential reporting system specifically for medication errors?

   1. AA. FDA
   2. BB. DEA
   3. CC. OSHA
   4. DD. ISMP
   Show answer to question 4

   Answer: D. ISMP

   The Institute for Safe Medication Practices (ISMP) operates a voluntary Medication Errors Reporting Program (MERP) that is confidential and used to analyze and prevent errors. FDA's MedWatch is for adverse events and product problems. DEA handles controlled substances. OSHA handles workplace safety.

   Why the other options are wrong

   • AFDA MedWatch is for adverse events, not specifically medication errors.
   • BDEA focuses on controlled substances.
   • COSHA focuses on occupational safety.

5. Question 5 of 25Medium

   A pharmacy quality team plans to implement a new secondary verification step for hazardous compounding. Before changing the procedure across the entire health system, they test the workflow in one satellite pharmacy for two weeks. Which step of the Plan-Do-Study-Act (PDSA) cycle does this small-scale trial represent?

   1. AA. Act
   2. BB. Do
   3. CC. Plan
   4. DD. Study
   Show answer to question 5

   Answer: B. Do

   The 'Do' phase of the PDSA cycle involves carrying out the plan on a small or pilot scale to test the proposed change and collect data. The 'Plan' stage focuses on establishing the objective and strategy, while 'Study' involves analyzing the collected trial data.

6. Question 6 of 25Hard

   During the sterile compounding of an intravenous chemotherapy agent, what is an essential element of an effective independent double check before the additive is introduced into the base bag?

   1. AA. Having the courier verify that the patient label on the final transport bag matches the compounding log sheet
   2. BB. Relying on the automated balance printout alone to confirm the identity and concentration of the drug
   3. CC. Having the compounding technician inject the drug and then present the empty syringe and empty vial to the checker
   4. DD. Having the verifier inspect the source vial, concentration, and volume measured in the syringe against the original order
   Show answer to question 6

   Answer: D. Having the verifier inspect the source vial, concentration, and volume measured in the syringe against the original order

   Checking the actual source vial, concentration, and measured syringe volume against the source order before injection ensures that errors in volume or drug selection are caught before the product is mixed. The 'pullback' method of showing an empty syringe after injection is unreliable and discouraged by safety organizations because it does not prove what was actually injected.

7. Question 7 of 25Medium

   Which of the following pairs of medications is a well-known look-alike sound-alike (LASA) pair that can lead to dispensing errors?

   1. AA. Lipitor and Zocor
   2. BB. Prozac and Paxil
   3. CC. Lamictal and Lamisil
   4. DD. Tylenol and Motrin
   Show answer to question 7

   Answer: C. Lamictal and Lamisil

   Lamictal (lamotrigine, an anticonvulsant) and Lamisil (terbinafine, an antifungal) are frequently confused due to similar spelling and pronunciation. ISMP lists them as a high-alert LASA pair.

   Why the other options are wrong

   • ALipitor and Zocor are both statins but have distinct names and are not typically confused as a LASA pair.
   • BProzac and Paxil are both SSRIs but have different brand names and are not considered a high-risk LASA pair.
   • DTylenol and Motrin are different active ingredients (acetaminophen vs. ibuprofen) and are not look-alike or sound-alike.

8. Question 8 of 25Easy

   A prescriber writes an order for a pediatric patient that includes the dose "morphine sulfate .2 mg IV". What is the primary safety hazard associated with this notation?

   1. AA. The dose may be misread as 20 mg, resulting in a hundred-fold overdose.
   2. BB. The dose may be misread as 2 mg, resulting in a ten-fold overdose.
   3. CC. The lack of a salt designation may lead to selection of the wrong chemical entity.
   4. DD. The order may be mistaken for an oral solution instead of an intravenous injection.
   Show answer to question 8

   Answer: B. The dose may be misread as 2 mg, resulting in a ten-fold overdose.

   Omitting a leading zero creates a naked decimal point that can easily be missed, leading a healthcare professional to read .2 mg as 2 mg and cause a ten-fold overdose. Guidelines require a leading zero before any decimal value below one, writing it as 0.2 mg to draw attention to the decimal point.

9. Question 9 of 25Hard

   A technician accidentally selected metoprolol 50 mg instead of metformin 500 mg from the shelf and dispensed it. The error was caught by the pharmacist before the patient took the medication. In a root cause analysis, which factor is most likely to have contributed to this error?

   1. AA. The pharmacist was distracted and did not check the product.
   2. BB. The technician entered the wrong NDC number into the system.
   3. CC. The two drugs have similar tablet appearance and are stored near each other.
   4. DD. The patient's name was similar to another patient's name.
   Show answer to question 9

   Answer: C. The two drugs have similar tablet appearance and are stored near each other.

   Metoprolol and metformin are well-known look-alike, sound-alike (LASA) drugs. Their tablet shapes, sizes, and colors can be similar, and they are often stored alphabetically on the same shelf. Root cause analysis often identifies such environmental factors (proximity, similar packaging) as primary contributors. Tall man lettering (e.g., metFORMIN vs. metOPROLol) and separating inventory are recommended error-reduction strategies.

   Why the other options are wrong

   • APharmacist distraction is a contributing factor, but root cause analysis focuses on system-level issues; the immediate cause was the technician selecting the wrong drug due to look-alike appearance.
   • BNDC entry error could occur, but the technician physically selected the wrong bottle; the root cause is more likely the visual similarity and storage proximity.
   • DPatient name confusion is possible but less likely in this scenario because the error was product selection, not patient identification.

10. Question 10 of 25Medium

    A customer with a history of hypertension asks the pharmacy technician for an OTC product to relieve nasal congestion from a cold. Which response is most appropriate for the technician?

    1. AA. Recommend phenylephrine 10 mg tablets.
    2. BB. Suggest an antihistamine such as diphenhydramine instead.
    3. CC. Explain that decongestants can raise blood pressure and refer the customer to the pharmacist.
    4. DD. Recommend pseudoephedrine 30 mg tablets.
    Show answer to question 10

    Answer: C. Explain that decongestants can raise blood pressure and refer the customer to the pharmacist.

    Both pseudoephedrine and phenylephrine are decongestants that can elevate blood pressure, posing a risk to patients with hypertension. The technician should not make an OTC recommendation without pharmacist assessment. The pharmacist can evaluate the patient's condition and recommend a safer alternative (e.g., saline spray, short-term use of a nasal corticosteroid) or advise if a decongestant is acceptable under monitoring.

    Why the other options are wrong

    • APhenylephrine also raises blood pressure, though less potent; it is still not recommended without pharmacist input.
    • BDiphenhydramine is an antihistamine that may cause drowsiness and is not indicated for nasal congestion; it does not directly address the customer's request and may not be safe in all patients.
    • DPseudoephedrine is a sympathomimetic that significantly raises blood pressure and is contraindicated in uncontrolled hypertension.

11. Question 11 of 25Medium

    A prescription is written for "Xarelto 20 mg" (brand rivaroxaban). The pharmacy stocks the generic rivaroxaban. The patient's profile notes an allergy to FD&C Yellow No. 5 (tartrazine), which is present in the generic tablet but not in the brand. What should the technician do?

    1. AA. Tell the patient to fill the prescription at a different pharmacy that carries the brand.
    2. BB. Order the brand product from the wholesaler without consulting anyone.
    3. CC. Dispense the generic as usual because the allergy is to a dye, not the active drug.
    4. DD. Notify the pharmacist so they can contact the prescriber to request dispensing the brand product.
    Show answer to question 11

    Answer: D. Notify the pharmacist so they can contact the prescriber to request dispensing the brand product.

    Therapeutic substitution to a generic is standard, but when a patient has a documented allergy to an inactive ingredient in the generic, the pharmacist must intervene. The pharmacist will contact the prescriber to authorize dispensing the brand (or an alternative generic without the allergen). The technician should escalate this to the pharmacist.

    Why the other options are wrong

    • ASending the patient elsewhere does not resolve the issue and is unprofessional; the pharmacy should attempt to accommodate the patient safely.
    • BOrdering brand without prescriber authorization is not allowed; the prescription is for the brand, but insurance may not cover it without a medical necessity override.
    • CDispensing the generic despite a known allergy to an inactive ingredient could cause a serious allergic reaction; patient safety requires intervention.

12. Question 12 of 25Medium

    A prescription for a patient reads: "Take 1 tab po qd #30." The drug name and strength are completely omitted. What is the technician's correct course of action?

    1. AA. Dispense the lowest available strength to be safe.
    2. BB. Refuse to fill the prescription and return it to the patient.
    3. CC. Place the prescription aside and ask the pharmacist to call the prescriber for clarification.
    4. DD. Assume the most commonly prescribed strength for that drug and dispense.
    Show answer to question 12

    Answer: C. Place the prescription aside and ask the pharmacist to call the prescriber for clarification.

    A prescription missing the drug name and strength is incomplete and cannot be filled. The pharmacist must contact the prescriber to obtain the missing information. The technician should recognize this as a critical error and bring it to the pharmacist's attention.

    Why the other options are wrong

    • ADispensing the lowest strength without knowing the intended drug is inappropriate and potentially harmful.
    • BRefusing to fill without attempting clarification is premature; the prescriber should be contacted first.
    • DAssuming the strength is dangerous and could lead to a wrong drug or dose; never guess on a prescription.

13. Question 13 of 25Easy

    A pharmacist is reviewing a new prescription for ibuprofen 800 mg TID for a patient who already has an active prescription for naproxen 500 mg BID. What is the most appropriate pharmacist intervention?

    1. AA. Contact the prescriber to discuss therapeutic duplication.
    2. BB. Advise the patient to take both at different times of the day.
    3. CC. Substitute ibuprofen with acetaminophen without contacting the prescriber.
    4. DD. Dispense both as prescribed.
    Show answer to question 13

    Answer: A. Contact the prescriber to discuss therapeutic duplication.

    Therapeutic duplication of NSAIDs significantly increases the risk of gastrointestinal bleeding and renal toxicity. The pharmacist must contact the prescriber to resolve the duplication before dispensing.

    Why the other options are wrong

    • BTaking both NSAIDs at different times still results in therapeutic duplication and increased risk.
    • CSubstituting a prescription medication without prescriber approval is outside the pharmacy technician's scope and is not appropriate.
    • DDispensing both as prescribed would expose the patient to unnecessary risk and is not a safe practice.

14. Question 14 of 25Hard

    Which statement accurately describes a recognized scientific limitation of data collected through VAERS?

    1. AA. Data cannot be evaluated by public health officials until one year after the report date
    2. BB. The system collects safety data exclusively for vaccines in their first year on the market
    3. CC. Reports are accepted only if an independent laboratory confirms biological contamination
    4. DD. A submitted report demonstrates a temporal association but cannot establish direct causality
    Show answer to question 14

    Answer: D. A submitted report demonstrates a temporal association but cannot establish direct causality

    Because VAERS is a passive, spontaneous surveillance system, a report indicates only that an event occurred after vaccination (a temporal link) and cannot alone establish that the vaccine caused the reaction. Distractors incorrectly state that pre-submission laboratory confirmation is mandatory or that surveillance excludes vaccines beyond their first year on the market.

15. Question 15 of 25Easy

    A patient stabilized on warfarin presents a new prescription for ibuprofen 400 mg three times daily. The pharmacy technician reviews the profile and identifies the interaction. What should the technician do next?

    1. AA. Alert the pharmacist to contact the prescriber about the increased bleeding risk.
    2. BB. Refuse to fill the prescription and tell the patient to go elsewhere.
    3. CC. Substitute the ibuprofen with acetaminophen without consulting anyone.
    4. DD. Dispense the ibuprofen as written since the prescription is valid.
    Show answer to question 15

    Answer: A. Alert the pharmacist to contact the prescriber about the increased bleeding risk.

    Warfarin and NSAIDs like ibuprofen significantly increase the risk of bleeding. The technician must recognize this drug utilization review (DUR) flag and refer it to the pharmacist, who will contact the prescriber to discuss alternatives or monitoring. Technicians cannot independently substitute or refuse a prescription without pharmacist direction.

    Why the other options are wrong

    • BRefusing to fill without pharmacist assessment is inappropriate; the pharmacist should first attempt to resolve the issue with the prescriber.
    • CTherapeutic substitution (e.g., changing to acetaminophen) requires prescriber authorization; a technician cannot make this change.
    • DDispensing without intervention ignores a serious drug interaction and violates patient safety standards.

16. Question 16 of 25Hard

    According to ISMP guidelines for high-alert medications, which storage practice is recommended to reduce the risk of errors?

    1. AA. Store high-alert medications in a separate, clearly labeled area with limited access
    2. BB. Store high-alert medications in the refrigerator regardless of stability requirements
    3. CC. Store high-alert medications alphabetically with all other medications
    4. DD. Store high-alert medications only in unit-dose packaging
    Show answer to question 16

    Answer: A. Store high-alert medications in a separate, clearly labeled area with limited access

    ISMP recommends segregating high-alert medications from other drugs, using distinct storage areas with clear labeling and limited access to reduce selection errors. Alphabetical storage increases risk. Refrigeration is not appropriate for all. Unit-dose packaging is a good practice but does not address storage location.

    Why the other options are wrong

    • BNot all high-alert medications require refrigeration; some may be degraded by cold.
    • CAlphabetical storage increases the risk of confusion with similar names.
    • DUnit-dose packaging is a packaging method, not a storage location strategy.

17. Question 17 of 25Hard

    A patient taking lisinopril contacts the pharmacy complaining of sudden, painless swelling of the lips, tongue, and throat that developed over the past hour. Which adverse drug event is this patient most likely experiencing?

    1. AA. Tardive dyskinesia
    2. BB. Angioedema
    3. CC. Stevens-Johnson syndrome
    4. DD. Serum sickness
    Show answer to question 17

    Answer: B. Angioedema

    Angioedema is a known, potentially fatal adverse drug reaction associated with ACE inhibitors like lisinopril, characterized by rapid swelling of the deep dermis, submucosal tissues, and airway. Stevens-Johnson syndrome is a severe adverse drug reaction marked primarily by painful blistering and detachment of the skin and mucous membranes rather than isolated rapid airway swelling.

18. Question 18 of 25Easy

    How does barcode scanning improve patient safety during the restocking of automated dispensing cabinets (ADCs) in a hospital?

    1. AA. It automatically calculates the billing charge to the patient's account.
    2. BB. It confirms that the medication is placed into the correct assigned pocket.
    3. CC. It extends the manufacturer expiration date of unit-dose medications.
    4. DD. It eliminates the need for any pharmacist final verification before use.
    Show answer to question 18

    Answer: B. It confirms that the medication is placed into the correct assigned pocket.

    Barcode scanning during cabinet restocking ensures that the medication being loaded corresponds precisely to the assigned compartment or drawer pocket, preventing wrong-pocket filling errors. It does not eliminate legal pharmacist oversight requirements or alter manufacturer-assigned expiration dates.

19. Question 19 of 25Easy

    After counting a non-sterile powder medication (e.g., amoxicillin capsules) on a counting tray, the technician prepares to count a different medication. What is the proper cleaning procedure for the counting tray?

    1. AA. Clean the tray with 70% isopropyl alcohol and allow it to dry before the next use.
    2. BB. Leave the tray as is because the next medication is also a powder.
    3. CC. Wipe the tray with a dry paper towel to remove visible powder.
    4. DD. Wash the tray with soap and water only at the end of the shift.
    Show answer to question 19

    Answer: A. Clean the tray with 70% isopropyl alcohol and allow it to dry before the next use.

    Counting trays must be cleaned between uses to prevent cross-contamination. 70% isopropyl alcohol is the standard disinfectant for non-sterile compounding surfaces because it kills most bacteria and fungi and evaporates quickly. Simply wiping or delaying cleaning risks transferring drug residues to the next product.

    Why the other options are wrong

    • BLeaving the tray un cleaned assumes no risk of contamination, which is incorrect even if the next drug is similar.
    • CA dry towel removes visible powder but does not disinfect the surface; microscopic contamination remains.
    • DWaiting until the end of the shift allows cross-contamination between multiple medications, which is unsafe.

20. Question 20 of 25Medium

    A patient asks a pharmacy technician for a recommendation for an OTC sleep aid. The patient mentions they take fluoxetine (Prozac) for depression. Which pharmacist intervention is most appropriate?

    1. AA. Recommend melatonin as a natural alternative.
    2. BB. Suggest the patient ask the prescriber for a prescription sleep aid.
    3. CC. Refer the patient to the pharmacist for evaluation of potential drug interaction.
    4. DD. Recommend diphenhydramine (Benadryl) as a sleep aid.
    Show answer to question 20

    Answer: C. Refer the patient to the pharmacist for evaluation of potential drug interaction.

    Fluoxetine is an SSRI; both diphenhydramine and melatonin can interact with it. The pharmacist must evaluate the patient's full profile before making a recommendation.

    Why the other options are wrong

    • AMelatonin may also interact with fluoxetine; the pharmacist should assess first.
    • BReferring to the prescriber bypasses the pharmacist's role; the pharmacist can evaluate and recommend appropriately.
    • DDiphenhydramine can increase anticholinergic effects and sedation when combined with fluoxetine; it is not recommended without pharmacist assessment.

21. Question 21 of 25Medium

    A pharmacy receives a prescription for oxycodone 10 mg #30 with the prescriber's signature but the DEA number is missing. What should the pharmacy technician do?

    1. AA. Contact the pharmacist to verify the prescription and hold it until the DEA number is obtained.
    2. BB. Look up the prescriber's DEA number online.
    3. CC. Dispense the prescription and call the prescriber for the DEA number later.
    4. DD. Refuse to fill and return the prescription to the patient.
    Show answer to question 21

    Answer: A. Contact the pharmacist to verify the prescription and hold it until the DEA number is obtained.

    For CII prescriptions, the DEA number is a required element. The pharmacist must verify and obtain the missing information before the prescription can be dispensed.

    Why the other options are wrong

    • BLooking up a DEA number online is not a valid verification method; the prescriber must provide it.
    • CDispensing without the DEA number is a violation of DEA regulations.
    • DReturning the prescription is premature; the pharmacy can contact the prescriber to obtain the missing DEA number.

22. Question 22 of 25Medium

    A patient reports experiencing a severe rash after starting a new antibiotic. The pharmacist suspects Stevens-Johnson syndrome. Which reporting system should the pharmacist use?

    1. AA. State Board of Pharmacy complaint form
    2. BB. DEA Form 106
    3. CC. ISMP Medication Error Reporting Program
    4. DD. FDA MedWatch
    Show answer to question 22

    Answer: D. FDA MedWatch

    MedWatch is the FDA program for reporting adverse drug events, including serious reactions like Stevens-Johnson syndrome.

    Why the other options are wrong

    • AState Board of Pharmacy handles complaints about pharmacy practice, not adverse drug event reporting.
    • BDEA Form 106 is used to report theft or loss of controlled substances, not adverse reactions.
    • CISMP is for reporting medication errors, not adverse drug reactions.

23. Question 23 of 25Hard

    Which safety requirement must be implemented when storing neuromuscular blocking agents in automated dispensing cabinets and pharmacy storage areas?

    1. AA. They must be placed in open, matrix storage bins with rapid-access overrides
    2. BB. They must be stored beside routine sedatives to facilitate rapid co-administration
    3. CC. They must be segregated and clearly labeled with auxiliary warning stickers
    4. DD. They must be shelved in general storage zones without special physical barriers
    Show answer to question 23

    Answer: C. They must be segregated and clearly labeled with auxiliary warning stickers

    Neuromuscular blocking agents cause total paralysis and respiratory arrest, requiring strict storage controls including segregation into dedicated, locked pockets or bins and distinct warning labels stating that the agent causes paralysis. Storing these agents in open matrix drawers or beside routine sedatives leads to catastrophic misidentification errors.

24. Question 24 of 25Hard

    A pharmacy technician is preparing a heparin infusion for a pediatric patient. To comply with the facility's independent double-check policy, which action best ensures the check is truly independent?

    1. AA. The technician recalculates the dose using a different formula and compares it to the first result.
    2. BB. The technician asks a colleague to perform the entire verification process without revealing the original calculations.
    3. CC. The pharmacist observes the technician's calculations and confirms they match the label.
    4. DD. The technician scans the barcode on the heparin vial and the infusion bag to verify the product.
    Show answer to question 24

    Answer: B. The technician asks a colleague to perform the entire verification process without revealing the original calculations.

    A truly independent double check has a second person perform the whole verification without seeing the original calculations, which prevents confirmation bias.

    Why the other options are wrong

    • AA self-check by the same technician is not a double check; it lacks the independent perspective of a second person and is prone to the same errors.
    • CObserving the technician's work introduces bias; the pharmacist may unconsciously confirm the technician's result rather than independently verifying.
    • DBarcode scanning verifies product identity but does not replace a cognitive independent double check of calculations and preparation steps.

25. Question 25 of 25Easy

    A pharmacy technician notices that a bin in the automated dispensing cabinet was restocked with the wrong drug concentration, but the error is discovered and corrected before any dose reaches a patient. How should this event be classified for internal quality reporting purposes?

    1. AA. A sentinel event
    2. BB. A near miss
    3. CC. An adverse drug reaction
    4. DD. A medication administration error
    Show answer to question 25

    Answer: B. A near miss

    A near miss is an error or unsafe condition that could have caused harm but was caught before it reached the patient, as happened with this restocking error. Tracking near misses helps fix system weaknesses before harm occurs.

    Why the other options are wrong

    • AA sentinel event involves unexpected death or serious harm to a patient, and no dose reached a patient here.
    • CAn adverse drug reaction is an unintended response to a medication that was actually taken, which did not happen here.
    • DA medication administration error means a wrong dose was actually given, but this error was corrected before any dose reached a patient.

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