Pharmacy Errors
MAT 510
Instructor: Dr.Guo
August 1, 2015

Simply knowing statistical tools and methods is not enough; one must understand the role that the science of statistics plays in managerial decisions. Managers need to think statistically. Statistical thinking is a philosophy of learning and action based on the following three principles: all work occurs in a system of interconnected processes, variation exists in all processes, understanding and reducing variation are keys to success. Understanding processes provides the context for determining the effects of variation and the proper type of managerial action to be taken. By viewing work as a process, we can apply statistical tools to establish consistent, predictable processes; study them; and improve them. While variation exists everywhere, many business decisions do not often account for it, and managers frequently confuse common and special causes of variation. We must understand the nature of variation before we can focus on reducing it. In this paper, the processes of prescription filling for HMO pharmacy will be analyzed.
A process is defined as a grouping, in sequence, of all the activities involved to accomplish one particular outcome and consists of suppliers, customers, material input, information inputs, transforming activities, inspections, delays, storage, transports, and outputs. To increase the chances of a successful project, mapping of key business processes is one of the most useful tools for directing and organizing an improvement effort. Process mapping is an easy-to-visualize method that can allow people to analyze and agree on the most efficient routes for reengineering or improving a process. It aids in determining redundant tasks, uncovering hidden interactions between processes and people, and focusing on the processes that serve customers, improve quality, and generate income(Savory & Olson, 2001).The identification of how a process or current system operates is the essential element in identifying improvement opportunities. Although process maps were initially developed for exploring manufacturing environments, they are useful in the analysis of any organizational process and can be a useful tool for improvement in healthcare.
Process Map
Receive Prescription > Verify Patients Info > Input Prescription Instructions > Search for Drug on the Prescription > Verify Total Amount of Pills to be Dispensed > Count Pills > Write down Company, Lot #, and Expiration Date > Fill Prescription Verified by Pharmacy > Bagged for Customer

Mapping of processes provides improvement teams a tool to look beyond functional activities and rediscover the core processes and essential elements of an organization. It does this by providing a visual technique for highlighting the “As Is” processes and showing “Should Be” processes. The results of process mapping are often quite surprising to most individuals because few have an accurate visual representation of how all the activities and processes fit into the big picture. As a result, the use of process mapping will increase the chance of a successful improvement effort. Members of the improvement team should include individuals who have a vested interest, knowledge, and involvement with the process; doctors, pharmacist, pharmacy tech, patient. The team should be cross-functional and have representatives from various levels of the organization.
SIPOC

Supplies –---> Pharmacy, Drugs
Input-----> Drug Company, Doctor
Process----> Confirming Order – Data Entry----Insurance Claim---Cross Check Drug Interactions---- Filling Prescription ---- Verify Filled Prescription by Pharmacist Output---> Verify Prescription with Customer – Being paid for prescription----Prescription Education Customer--- Customer satisfaction
Doctors are famous for sloppy scribbling -- and handwritten prescriptions lead to thousands of medication errors each year. A simple mistake such as putting the decimal point in the wrong place can have serious consequences because a patient's dosage could be 10 times the recommended amount. Drugs with similar names are another common source of error. Dispensing errors include any inconsistencies or deviations from the prescription order, such as dispensing the incorrect drug, dose, dosage form, wrong quantity, or inappropriate, incorrect, or inadequate labeling. Also, confusing or inadequate directions for use, incorrect or inappropriate preparation, packaging, or storage of medication prior to dispensing are considered to be errors. According to PharmacyTimes, “errors occur at a rate of 4 per day in a pharmacy filling 250 prescriptions daily, which amounts to an estimated 51.5 million errors out of 3 billion prescriptions filled annually nationwide.(Santel, 2003)”
One main root cause of the problems in the pharmacy are prescription data entry. The cause is common. The common cause variation arises from a multitude of small factors that invariably effect any process and will conform to a normal distribution, or a distribution that is closely related to the normal distribution. Transcription errors would cause dispensing errors. The errors can be reduced by using reliable methods (proofreading) to verify patient identity while entering the prescription into the computer. This helps prevent medication errors due to sound-alike, look-alike names. As shown in the SIPOC (above) it is useful to have information about the patient, such as the age of the patient, allergies, concomitant medications, and contraindications.
The measurement process includes all the steps listed in the SIPOC component. Business process should be analyzed by charting errors to see if and where the problem exist and making adjustments to the process. Sometimes, a process has to be re-evaluated to ensure accuracy. A lot of hospitals have switched to computerized physician order entry systems which has reduced HMO pharmacy errors by 61% (Flynn, 1999).
In this case study the need to reduce errors are essential to having gainful employment and lowering lawsuits. The process map and SIPOC is a start in eliminating and identifying problem areas. With the information given, hopefully everyone is able to keep their job with the assumptions given.

REFERENCE

Flynn EA, et al. Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy. Am J Health Syst Pharm 1999 Jul 1;56(13):1319-25.

Santell JP, Hicks RW, McMeekin J, Cousins DD. Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol. 2003; 43: 760-767.