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Table 4 Effects and causes of identified failure modes common to both teamsa

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

Causes of failure modes identified by both teams Relevant failure mode/s number/s (failure mode numbers are according to Table 2.)
Overcrowded medication counters 1, 2, 3, 4, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35, 41
Pharmacists working long hours without a break due to inadequate staff 5, 6, 7, 8, 12, 13, 14
Unclear prescriptions 5, 6, 7, 8, 35
Improper arrangement of dispensing tables 10, 11
Not rechecking the dispensed medications 12, 13, 14, 28, 29, 31, 32
Negligence/poor attention by pharmacist 10, 12, 13, 14, 16, 17, 18
Environmental distractions and interruptions 22, 23, 31, 33, 42
Improper/ unclear labels attached to the pre-packed medication packs 10
Poor communication with patients 9, 19, 20, 35, 40
Effects of failure modes identified by both teams
 Patient receiving wrong medication
 Patient receiving wrong dose of medication
 Patient receiving wrong quantity of medication
 Patient taking medications incorrectly due to unclear instructions (verbal and/or written)
 Patient does not achieve the intended therapeutic outcome which will lead to loss of medication adherence
 Patient does not receive all required medications
 Patient receives unnecessary medications (e.g. omitted medications/ medications prescribed in a previous visit)
 Another healthcare professional will not able to identify the medications taken by the patient if allergy develops or treat other health condition when medication name is not indicated on the label
 Patient medication histories and hospital copy of the patient’s prescription are lost/misplaced if medications were dispensed from the wrong pharmacy counter
  1. aFMEA spread sheets are available as supplementary material for further details