The pharmacist in this case was implementing changes in the pharmacy processes at the time the patient recieved the wrong medication. How might these system changes have contributed to the error that occured?
In the book, “Patient Safety for Health Professionals” it states, “A newly hired pharmacy manager was challenged to transform exisitng pharmacy policies to new systems as a store underwent conversion from one grocery chain to another. During those intial weeks, work was hectic, and many prescriptions were being filled for exisitng patients as well as for new pharmacy customers. The pharmacist, aided by a pharmacy technician, was responsible for filing these prescriptions while adjusting to the new pharmacy practices. The pharmacy technician typically filled the prescription, and the pharmacy double checked and approved the medication. They both had to sign the reciepe containing the medication information confirming the dose and type. All labeled vials and storage containers were placed in a basket with the written perscription to avoid misplacing any medications. Despite these measures, the wrong medication, a narcotic schedule II-controlled substance, was given to an unsuspecting patient during that inital period of adjustment. An unlabled amber contianer with tablets sitting near the basket containing a prescription order but nothing else. It was 11:00 a.m., a busy time in the pharmacy when call-ins pour in before lunch hour. The patient whose name was on the prescription order in the basket was waiting. The pharmacists thought the amber container had come from the basket. The technician was busy completing another job. The paperwork was already intialed, and thus, the pharmacist labeled the vial, checked for contents, and proceeded to give the prescription to the customer. Several minutes later and to their dismay, the pharmacy technician and the pharmacist both realized a mistake had been made. In the midst of a busy time, the pharmacy technician forgot about the unlabeled container and was still working on the order the pharmacist completed and gave to the patient. The unlabeled vial contained a very similar-looking medication, but happened to be a controlled analgesic that had nothing to do with the patient’s required drug thearpy. Fortunately, the alarmed pharmacist was able to drive to the patient’s house that afternoon and exchange the medication before the medication was taken. The patient was somewhat concerned, but actually more pleased with the reception of a gift certfiicate. As a resuly of this incidient, the pharamicst and the pharmacy technician have worked out a new system in which unlabeled vials of medicine are not to be place on the counter of the filling area and all final signatures are not to be completed until the baskets contain the properly labeled medications. The pharmacist also carefully reviews the drug order information sheet in which a physical description of the drug is provided, including any stamped letter or symbols. She intials this description after every examination.”
1. Can you identify a “slip” in this case? A “mistake”? A “latent error?”
2. The pharmacist in this case was implementing changes in the pharmacy processes at the time the patient recieved the wrong medication. How might these system changes have contributed to the error that occured?
3. As a result of the error that occured, the pharmacist and pharmacy technician made design changes in the process for dispensing medication. Evaluate these changes, and describe why they may reduce errors and improve patient safety using principles introduced.
"You need a similar assignment done from scratch? Our qualified writers will help you with a guaranteed AI-free & plagiarism-free A+ quality paper, Confidentiality, Timely delivery & Livechat/phone Support.
Discount Code: CIPD30
Click ORDER NOW..
