Essay On Prescribing Medication Errors

The process of prescribing medication is complex and involves many individuals seamlessly collaborating together in order for the process to flow smoothly. The prescribing process has numerous areas which can cause errors to providing the patient with the correct prescription. There are four main parties responsible for prescription errors: the physician, the pharmacist, the nurse, or the patient. A breakdown between any of these individuals could lead to a medication error. The Division of Medication Error Prevention and Analysis (DMEPA) defines a medication error as, “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient,

or consumer.” (“Medication Errors Related to Drugs”). In order to improve the prescription process, you must first understand the current process.
The current prescription process has three distinct phases: physician prescribing, pharmacy fulfillment of prescription, and distribution of the prescribed medication to the patient. During the physician prescribing phase, the first step in the process is the physician’s diagnosis of the the patient’s condition. Based upon this diagnosis, the medication and dosage is determined and the physician transcribes the prescription to be sent to the pharmacy. The final process of the prescribing phase is the physician’s instruction to the patient about the medication. The second phase is the pharmacy fulling the received prescription. During this phase, the pharmacist fills the prescription according to the received prescription choosing the medication and dosage prescribed by the physician. This medication is then bottled and labeled with the medication’s information as well as the patient’s information. The final main phase is the distribution of the prescribed medication to the patient. During this phase, the patient actually receives the medication and dosage which was filled by the pharmacist and prescribed by the physician.
Identifying root problem areas in the process is the first step in determining where any potential changes need to be implemented. In the prescription process, the root issues are: ensure the correct medication/dosage is being prescribed, ensure the correct medication/dosage is chosen when filling the prescription, and make sure that the correct medication/dosage is being dispensed to the patient. If these three root areas are addressed and safeguarded, then the amount of prescription errors will greatly decrease. All three of these main root problems are almost always due to some variation of human error and would be classified as common-cause variation.
Using the SIPOC model to analyze the prescription filling process we are better able to understand where any potential errors can occur. In the SIPOC model, the supplier for the medication is the individual pharmaceutical companies such as Pfizer, Sanofi, and AstraZeneca. These companies are responsible for manufacturing the medication and then supplying this medication to the pharmacies for distribution to the patient. There actually are few errors that occur during this manufacturing of the medication phase. This is due to the constant checks, high standards and scrutiny, and having to abide by Food and Drug Administration (FDA) policies. The pharmaceutical companies are held to very high standards due to never wanting to provide incorrect or unsafe medication to the public. However, unlike the prescription process where an error would only affect a patient or two, an error at a pharmaceutical company would affect thousands of people. Many of those potential errors could have devastating results to the patient and cause serious illness, damage, or even death. This could very easily have monumental repercussions for the company in both the short and long term. Therefore, these pharmaceutical companies do everything they can to stabilize their processes and have absolutely no mistakes. With all that said, this would almost certainly have no effect on the errors that are occurring in the prescription process.
In the SIPOC model, the input would be the actual prescribing and transcribing of medication. There are many ways in which errors can occur during this phase of the prescription process. One error that could occur during this phase would be misdiagnosis of the patient’s condition by the physician. With a misdiagnosis, the incorrect medication for the patient’s condition would be prescribed therefore causing an incorrect medication error from the onset. Another potential problem can occur by not properly assessing the patient’s needs or medical history. An example of this would be prescribing medication to treat a particular condition without regards to other medication the patient could be taking or other health issues the patient may be having. Another example of potential errors would be the physician accidentally writing the incorrect medication on the prescription, or another common problem is the physician simply choosing the incorrect dosage. Physicians are very busy, seeing numerous patients throughout the day, and going from patient to patient can provide confusion if the physician loses their focus. This also can easily occur as physicians attempt to do too much instead of taking their time and focusing on the task at hand. One easy solution for these issues would be “another physician or nurse reading back the prescription to the prescribing physician to ensure the medication is transcribed correctly.” (Vickerie). Another good transcribing practice is to “place a zero in front of the decimal point. A dosage of .25 mg can easily be confused with 25 mg.” (Vickerie). Yet another possibility for error can occur if the physician’s instructions to the patient about the medication are unclear or confusing. Making sure the patient understands which medication they are being prescribed and the dosage they will need to take is very important to the ensuring the patient takes the medication as prescribed. Taking the medication as prescribed is vital to the effectiveness of the medication; otherwise the patient risks overdosing or underdosing. One potential process improvement would be not only does the prescribing physician provide instruction about the medication but then the nurse goes over the medication a second time with the patient before they are discharged, allowing the patient to ask any questions they may have. Along with this step, typed instructions can be given to the patient in regards to the medication. This will allow the patient to review the instructions whenever needed so they will not have to remember everything being told to them.
During the SIPOC model, the process steps would be the pharmacist and the process of actually filling the prescription order for the patient.

Like the previous step, this step also has many possibilities for errors. The first of these can occur if the prescription is unclear or illegible. Unreadable handwriting can make it very difficult for a pharmacist to determine which medication and dosage was actually prescribed by physician, and leaves a variety of outcomes in regards to the medication that the patient will receive. Another possible error would be the pharmacist inadvertently choosing the incorrect medication when filling the prescription. Or to further complicate things, the pharmacist could mix up the prescriptions and swap the medications provided to patients, putting the medication for patient “A” in the bottle for patient “B” and vice versa. This would be twice as bad due to the error effecting two patients instead of just one. If this wasn’t bad enough, yet another error that can occur would be the pharmacist mislabeling the bottle that the medication is put into. These medication bottles are labelled with the medication and dosage information, as well as the patient’s information. Therefore, any error in this label could provide either: the incorrect medication, the incorrect dosage, or dispense the medication to the incorrect

patient.
In the SIPOC model, the output phase would be dispensing or providing the medication to the patient. The biggest error in this step would be distributing the incorrect prescription to the patient. Incorrect medication can potentially have very adverse effects on the patient, but at the very least the medication would not be very effective in treating the patient’s issue. This would also be one of the easiest areas to prevent errors, as simply verifying and collecting patient information before issuing the medication would help to prevent any such issue from occurring.
Finally in the SIPOC model, the customer is the patient who receives the prescription. The main error that occurs during this step would be a patient incorrectly taking the medication or dosage. This could easily occur if the patient has multiple medications they are taking. A few of the possible errors that can occur are: mixing up which medication is which, forgetting when to take each particular medication or for what duration to continue taking a medication, failing to follow the physician’s instructions or reading the label on the medication bottle, and/or taking a dosage other than what has been instructed to the patient. Another very possible error that occurs when the patient is taking multiple medications is forgetting when they have previously taken which medication. Assuming the patient received correct instruction, medication/dosage, and labeled medication from the pharmacist, then all of these errors are due to patient error and the lack of attention to detail. If the above scenario is the case, then these variations would be considered special cause variation. Unfortunately, these errors would also be the most difficult to correct due to the patient no longer being in direct contact with the physician, pharmacist, nurse, or any other control that was established to prevent mediation errors. What makes it even more difficult is the “user error” aspect of the problem, as all of the other individuals completed their due diligence, everything verified, and the correct medication/dosage was distributed.