Fundamentals Of Medication Error Research Essay


Develop a process map about the prescription filling process for HMO's pharmacy, in which you specify the key problems that the HMO's pharmacy might be experiencing. Next, use the supplier, input, process steps, output, and customer (SIPOC) model to analyze the HMO pharmacy's business process. Analyze the process map and SIPOC model to identify possible main root causes of the problems. Next, categorize whether the main root causes of the problem are special causes or common causes. Provide a rationale for your response. Suggest the main tools that you would use and the data that you would collect in order to analyze the business process and correct the problem. Justify your response.


The HMO Pharmacy is a very important part of medical and treatment system. The prescription filling process is the most integrated part of the system, where patient finally get their drugs prescribed to them, so that they can recover. Thus, any mistake that takes place in this process can lead to serious issues, and in some cases, even prove fatal for the serious patients. As we can see in the case study, when this scenario of errors in the prescription filling arises, legal measures are taken against the person responsible, and hence, is the issue with Juan de Pacotilla.

The process of prescription filling involves a number of steps, in which, many a times, guesses and decisions are to be made. Hence, a minimum qualification is required for the person who takes up the job of prescription filling. The process involved in this system includes the following in sequence: The pharmacy first receives the order for prescription filling. If the order is for renewal, the pharmacy has to call the physician for approval of the renewal of prescription. If it is approved by the physician, the filing process is started. If it is not approved, the customer is advices to consult the physician for the same, and the prescription is returned. If the prescription is not for renewal, the process of filling is started. The Rx is entered into the system, which is generally a computer based software for HMO. The insurance information of the patient is then checked. The insurance plays an important role at this step, as if the insurance is valid, the customer is not directly charged for the filling of prescription. But if the insurance is not valid or not available, the patient is charged for the filling of prescription directly, which they can pay by various modes of payment like cash, card etc. After this step, the prescription is put into the queue for the filling of the prescription process. The pharmacist or the person who is responsible for the job, who might be the technician working there, checks and counts the number of pills or medicine, and put them aside for filling. When the Rx is filled by the pharmacist, the label for the medicine is prepared. The label includes the name of the patient, the date of filling of prescription, the name of the doctor, and possibly the expiration date of the medicine. There can be other information as well, like the name of the HMO, the name of the pharmacist filling up the prescription, the order number etc. The label is then printed and glued to the bottle of medicine which has been filled by the pharmacist. If the medicine has not been filled by the pharmacist, the Rx is then reviewed again for filling. The completed Rx and the bottle with the medicine is then placed in a basket which stores the completed orders. The medicine is ready for pickup at this stage. Before the actual delivery or pickup of the order, the customer ID is verified for the Rx, and the process is forwarded. The customer is then handed over the medicine which has been filled up. If the customer has any query or questions, it is entertained by the pharmacist. If the pharmacist is unable to resolve the query, it is forwarded to the pharmacy technician. The query is resolved, and the customer is asked to pay, if needed. If they have a standing insurance, the payment process is skipped. The process of filling the prescription, hence, ends here.

The process has been explained in the form of a flowchart below:

By analysing the process map for the process of filling up the prescription, we can see that there are few weak joints in the process, where problem can arise. There may be the cases when a fake prescription is received by the pharmacy for filling up. The verification in such a case becomes difficult, and many a times, the pharmacist is held responsible for the same. There can be incidents when the prescription is not clear due to handwriting of the doctor, and pharmacist may misunderstand the drug for some other medicine with similar name, and can cause health problems to the patients. The queries that are raised by the customers may also sometime be too deep to be in the scope of knowledge of a pharmacist to answer.

The data can be analysed for number of incidents when a wrong Rx is filled up for the prescription by a pharmacist. The data can be correlated for the number of times this error occurs with the name of the doctor issuing the prescription. In this analysis, it can then be understood that there might be more number of incident with some particular doctor or doctors, who might have a habit of writing in non-understandable handwriting, more often. The data can also be analysed for some specific medicines prescribed, if number of problems arises then, and can be checked of some medicines are more prone to have been misread. (Allan and Barker, 1990)

The problem of bad handwriting in the prescription which leads to error in the filling up of prescription process can be resolved if it is made a standard that all the prescriptions are to be computer typed and printed. If the prescription is typed, there would not be any issue of misreading the name of the medicine and the error would be avoided to a great extent. This would also end the blame game of every person involved in the system for the wrong handwriting. The prescription can also be made electronically available to the pharmacy, which would reduce the chances of fake and false prescriptions. Automatic prescription filling mechanism can also be implemented to resolve the issues. (Williams, Welin, Mathews, Towle & Orrick, 1997)

After implementation of the computer printed prescription, the data can then be collected for number of errors, and it can be analysed that who is at the actual fault here. The number of errors in filling up of the prescription would ideally reduce, and if not, the qualification standards of the pharmacists will have to be increased.


Williams, J. P., Welin, D., Mathews, R., Towle, A., & Orrick, A. (1997). U.S. Patent No. 5,597,995. Washington, DC: U.S. Patent and Trademark Office.

Allan, E. L., & Barker, K. N. (1990). Fundamentals of medication error research. American Journal of Health-System Pharmacy, 47(3), 555-571.

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