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 |