NAPLEX (North American Pharmacist Licensure) Exam

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A patient on a medical-surgical unit experienced a severe hypoglycemic event. A root cause analysis (RCA) revealed the patient received glipizide instead of glyburide, which had been ordered. The investigation found that the two drugs were stored in adjacent bins in the automated dispensing cabinet (ADC) on the nursing unit. Which of the following interventions represents the strongest system-based change to prevent this error from recurring?

Requiring two nurses to verify all sulfonylurea administrations. Implementing barcode scanning for medication removal from the ADC and at the bedside. Placing a high-alert warning sticker on the glyburide and glipizide bins. Educating all nursing staff on the differences between glipizide and glyburide during the next staff meeting.

Correct Answer:

Implementing barcode scanning for medication removal from the ADC and at the bedside.

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