Reference no: EM133169820

READ:

Mission Street Clinic is a community-based clinic system that serves more than 4 million residents in a major urban area on the West Coast. The organization is highly regarded for the service it provides to members of all demographic and socioeconomic strata. Each day, the clinic sees more than 1,000 patients across its various sites.

The organization has been maintaining its records on paper, and its dedicated staff has managed to keep the clinic operational despite minimal automation. Members of the staff have worked with one another for decades and have established a significant level of comfort and trust. They rarely question any provider's decisions or judgment. The pharmacy on the premises handles thousands of prescriptions each day using a mostly paper-based system and handwritten prescriptions. The pharmacy team has recently experienced turnover, with the retirement of two pharmacists. Because of budget cuts, a pharmacy technician position is unfilled.

Recently, the organization has experienced six episodes in which an incorrect prescription was filled and a patient was nearly harmed. Three of the episodes were recognized within the pharmacy itself and rectified. Two of the episodes were discovered at the end of the shift, and the patients were able to be called back for a prescription change before they took the medication. One episode stemmed from difficulty in deciphering the prescriber's prescription.

Although none of the episodes led to harm, the staff is concerned that the clinic's quality and reliability are slipping. As the clinic's CEO, you have been asked by the board to research the issue and provide recommendations.

ANSWER THE QUESTIONS:

Are the medication errors a cause for concern? If harm did not occur, is action necessary? Why or why not?

What strategies will you employ to gain more insight into the causes of the near misses? Search the relevant literature and incorporate key findings into your answer. Who would you interview to learn details about the issues?

The pharmacists advise you that, because they have worked together for so long, they do not feel the need to verify one another's work. Policies, however, clearly require a second check. Would this be considered a violation of policies and procedures? Is respect for a just culture reasonable in this situation? How will you balance the need to ensure compliance with policies and procedures while acknowledging the transparency demonstrated by the pharmacists?

You decide to conduct a root cause analysis of the near misses. Propose a methodology for identifying the causative factors contributing to the problems with medication prescription.