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Table 2 Failure modes identified by Failure Mode and Effects Analysis and their Risk Priority Numbers

From: Application of failure mode and effects analysis (FMEA) to improve medication safety in the dispensing process – a study at a teaching hospital, Sri Lanka

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
  1. RPN A Risk Priority Numbers assigned by Team A; RPN B Risk Priority Numbers assigned by Team B