Table 2 Failure modes identified by Failure Mode and Effects Analysis and their Risk Priority Numbers
Common failure modes identified by both Team A and Team B | ||
|---|---|---|
Failure mode | RPN A | RPN B |
1 Patient is issued a clinic prescription card belonging to another patient by mistake | 20 | 6 |
2 Pharmacist dispenses medications to a clinic prescription that should have been dispensed at another clinic dispensing counter | 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 | 15 | 16 |
6 Pharmacist unintentionally misses dispensation of some medications in long prescriptions | 24 | 4 |
7 Pharmacist fails to identify prescribing errors on prescriptions | 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 | 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 | 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 | 4 | 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 | 4 | 3 |
24 Pharmacist fails to document accountable medications | 24 | 4 |
Failure modes identified by Team A only (but scored by both teams) | ||
25 Pharmacist incorrectly guesses information on unclear prescriptions | 8 | 18 |
26 Pharmacist uses an envelope with an incomplete or unclear label stamp to pack medications | 12 | 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 | 12 | 8 |
29 Pharmacist fails to fill a labeled medication packing envelope | 18 | 4 |
30 Leaflets may be unavailable in different languages (e.g. Tamil) | 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 | 12 | 4 |
33 Pharmacist dispenses or patient takes wrong medication packets which are left on the dispensing table | 18 | 8 |
34 Pharmacist fails to update the accountable medication in manual log books daily | 5 | 2 |
Failure modes identified by Team B only (but scored by both teams) | ||
35 Pharmacist accidentally mixes-up prescriptions of two paediatric patients from the same family | 6 | 12 |
36 Pharmacist marks available medications as out of stock medications | 1 | 12 |
37 Support staff (non-pharmacist) accidentally packs a wrong medication into pre-packed and sealed medication packets | 12 | 12 |
38 Pre-packed medication packs may contain expired medications | 9 | 9 |
39 Pre-packed medication packets may be left for longer duration after packing | 6 | 8 |
40 Pharmacist gives only written medication directions to illiterate patients without verbal/pictorial communication | 3 | 12 |
41 Pharmacist fails to check the expiry date of the medication | 9 | 6 |
42 Pharmacist accidentally fills a wrong prescription given by another patient | 3 | 6 |