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1 Patient is issued a clinic prescription card belonging to another patient by mistake
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20
|
6
|
|
2 Pharmacist dispenses medications to a clinic prescription that should have been dispensed at another clinic dispensing counter
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8
|
8
|
|
3 Pharmacist does not check the clinic registration number of the patient
|
20
|
6
|
|
4 Pharmacist does not check the date of the prescription and age of the patient
|
16
|
24
|
|
5 Pharmacist misreads the medication name, dose or strength leading to wrong drug error when dispensing
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15
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16
|
|
6 Pharmacist unintentionally misses dispensation of some medications in long prescriptions
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24
|
4
|
|
7 Pharmacist fails to identify prescribing errors on prescriptions
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12
|
24
|
|
8 Pharmacist misreads the duration of the prescription leading to dispensation of the wrong quantity of medications
|
8
|
12
|
|
9 Pharmacist does not notify patient on out of stock medications
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12
|
16
|
|
10 Pharmacist picks up the wrong medication packet (pre-packed) without checking the label
|
30
|
12
|
|
11 Pharmacist picks up the medication packet (pre-packed) with the wrong quantity
|
20
|
12
|
|
12 Pharmacist incompletely labels the medication packet having hand-written or partially hand-written labels
|
27
|
24
|
|
13 Pharmacist accidentally transcribes an incorrect dose or frequency to the medication label
|
36
|
6
|
|
14 Pharmacist writes directions (dose, frequency, before/after meals) in unclear handwriting
|
12
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18
|
|
15 Pharmacist picks the wrong medication container from the dispensing shelf
|
8
|
8
|
|
16 Pharmacist does not check the physical appearance of medications in the container before preparation to assess colour and shape of medications for any decompositions
|
18
|
8
|
|
17 Pharmacist counts the wrong quantity of medications
|
40
|
16
|
|
18 Pharmacist fills the medications to a wrong envelope which was labelled for another medication
|
6
|
12
|
|
19 Patient does not understand the language of written instructions and/or verbal instructions given by the pharmacist
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4
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4
|
|
20 Pharmacist fails to tell some important information when giving verbal instructions briefly
|
12
|
12
|
|
21 Pharmacist gives incomplete instructions for external preparations and/or only give verbal instructions without written instructions (e.g. dermatological preparations)
|
18
|
12
|
|
22 Pharmacist fails to give verbal instructions
|
18
|
8
|
|
23 Leaflets may be unavailable and/or pharmacist may forget to give it to the patient
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4
|
3
|
|
24 Pharmacist fails to document accountable medications
|
24
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4
|
|
Failure modes identified by Team A only (but scored by both teams)
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|
25 Pharmacist incorrectly guesses information on unclear prescriptions
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8
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18
|
|
26 Pharmacist uses an envelope with an incomplete or unclear label stamp to pack medications
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12
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8
|
|
27 Pharmacist fails to check the quality of the medication packing envelope
|
15
|
2
|
|
28 Pharmacist fills the medications into an unlabeled medication packing envelope
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12
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8
|
|
29 Pharmacist fails to fill a labeled medication packing envelope
|
18
|
4
|
|
30 Leaflets may be unavailable in different languages (e.g. Tamil)
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4
|
2
|
|
31 Pharmacist fails to dispense some filled medication packets to the patient
|
12
|
18
|
|
32 Pharmacist dispenses unfilled medication packets to the patient
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12
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4
|
|
33 Pharmacist dispenses or patient takes wrong medication packets which are left on the dispensing table
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18
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8
|
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34 Pharmacist fails to update the accountable medication in manual log books daily
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5
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2
|
|
Failure modes identified by Team B only (but scored by both teams)
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|
35 Pharmacist accidentally mixes-up prescriptions of two paediatric patients from the same family
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6
|
12
|
|
36 Pharmacist marks available medications as out of stock medications
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1
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12
|
|
37 Support staff (non-pharmacist) accidentally packs a wrong medication into pre-packed and sealed medication packets
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12
|
12
|
|
38 Pre-packed medication packs may contain expired medications
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9
|
9
|
|
39 Pre-packed medication packets may be left for longer duration after packing
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6
|
8
|
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40 Pharmacist gives only written medication directions to illiterate patients without verbal/pictorial communication
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3
|
12
|
|
41 Pharmacist fails to check the expiry date of the medication
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9
|
6
|
|
42 Pharmacist accidentally fills a wrong prescription given by another patient
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3
|
6
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