2 Jun 2022


Pharmaceutical Medication Errors

Format: APA

Academic level: University

Paper type: Case Study

Words: 902

Pages: 3

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From the case study, the pharmacy is faced by challenges caused by their prescription process. It is evident that there are gaps that exist in the process leading to prescription errors. It is, therefore, necessary to identify the cause of such mistakes to come up with an appropriate solution 

Different medication errors occur in the pharmaceutical patient care. Some of the issues include prescription errors, prescribing faults, dispensing errors, administration errors, transcription errors and across setting errors. Among the errors mentioned, dispensing error is the most prevalent. This error occurs if there is a discrepancy between what has been prescribed and the medicine that the patient ultimately receives. Where quality is concerned, such errors will involve failure to detect prescription and manufacturing mistakes and to make the necessary correction. Errors can take the following forms; medicine can be dispensed to the wrong patient, dispensing at the wrong time or wrong medicine or of a different strength level. Similarly, the incorrect quantity, dosage, or an expired drug can be administered. Other instances include failure to dispense, wrong compound medicine, or inferior quality medicine just to name the most common issues but there is a myriad of different errors that can be categorized as dispensing (Merry, 2011; Webb, 2015; WHO, n.d). 

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Process map about the prescription filling process at HMO Pharmacy 

The following is a process map describing the prescription filling process of the pharmacy. Each level has some errors that can be identified in them. Identifying the mistakes that affect each phase will help the store to come up with strategies for reducing the errors. This is determined by its working level in the medication process and the extent of information technology used. The primary causes of dispensing errors are illegible handwriting, inadequate controls, interruptions and similarities in the drugs (Merry, 2011; WHO, n.d). 

Using the process map, errors that affect the initial stages include wrong drugs, to the right patient and the vice versa, allergies towards certain medicines and interactions, incorrect doses, and form/ route. The doctors can transcribe the wrong dose, route, to the wrong patient at an inappropriate time and use the wrong drugs. When the drugs are dispensed, the wrong dose can be issued, using inappropriate routes, to the wrong patient at an incorrect time. Similarly, there can be errors in labeling or allergic reactions. While administering drugs, the wrong patient or dose can be used. Similarly, there can be issues with the bad drugs, omission, wrong route, and time (Webb, 2015; WHO, n.d). 

Combining the process map and the SIPOC model, it is possible to break down the different step. The first phase represents the supply where the doctor and the patient interact. The selection and writing down of the prescription can be equated to the input. The process takes place from the point the patient takes the prescription to the clerk to the moment the pharmacist gives out the medication. Output starts when the pharmacist gives out the drugs to the clerk. Customer represents the moment the patient takes medicine from the clerk and consume it becoming sick. The above model shows the entire process of the Pharmacy. It clearly maps out the process with points that clearly indicate the SIPOC elements (Webb, 2015; WHO, n.d). 

Some of the challenges faced by Ben stem out from a poorly organized process in the Pharmacy from the time a patient arrive until he or she exit. There might be cases of stock outs, but adequate checks are not in place. There is no verification of the prescription and errors might occur at any point in the process. The prescription presented at the counter should be counterchecked with the doctor. Similarly, a new interconnected system can be developed that ensures the doctor personally enters the prescription into the system. Such a system provides that errors from illegible handwritings are minimized. The pharmacy should also have a clear data management system where patients’ records are accurately recorded and stored (Webb, 2015; WHO, n.d). 

All medicines to a particular patient should be recorded in the system and verified by a different person. Checks should be put in place to ensure that the pharmacist measures the drugs correctly. Periodic checks of equipment and apparatus should be carried out. Controls should be put in place to ensure that the pharmacy is giving out the right medicine at the right time and to the right patient. Lastly, the patient should be informed on how and when to take medicine and to seek immediate health care services if the condition worsens or if they experience negative reactions from taking the drugs (Webb, 2015; WHO, n.d). 

Once the errors have been identified, the next step is to develop a solution to the recurring problem. It would be necessary to collect relevant information concerning customer complaints and determine the point at which the errors occurred. Statistical tools like SPSS can then be used to analyze the data to come up with a clearer picture of the exact point at which the errors occurred. Descriptive statistics can be used to determine the tendency in which identified errors cluster around a particular element of the SIPOC model. Similarly, inferential statistics can be used to analyze sample data and come up with a generalized conclusion. Additionally, ANOVA can be used to analyze variance in two or more groups of patients who have received the wrong prescription (de Smith, 2015). 

The Pharmacy can automate its entire process. Doing so will eliminate errors that take place. The system should enable the counterchecking of information before the drugs are released to the patient. Similarly, the system should contain information concerning the level of stock. It should indicate available stock, the expiry date, and available substitutes. The system should allow for customer feedback on services received and their level of satisfaction (Webb, 2015; WHO, n.d). 


De Smith M J (2015) Statistical analysis handbook: a comprehensive handbook of statistical concepts, techniques and software tools . The Winchelsea Press, Winchelsea, UK 

Merry, A. F., & Anderson, B. J. (2011). Medication errors - new approaches to prevention.  Pediatric Anesthesia,    21 (7), 743-753. doi:10.1111/j.1460-9592.2011.03589.x 

Mukherjee, S. (2015, November 15). Hospital’s Six Sigma and lean efforts benefit patients and profitability. Retrieved April 25, 2017 

Webb, J. (2015, March 10). Pharmacy dispensing errors: Claims study emphasizes need for systematic vigilance. Retrieved April 25, 2017 

WHO, (n.d). Chapter 30 Ensuring good dispensing practices – World Health Organization. Retrieved April 25, 2017,  

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StudyBounty. (2023, September 15). Pharmaceutical Medication Errors.


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