Table 3.

Sample Quotes from Participants Related to Identified Themes

Theme	Quote from Participants
Memorization	“I don’t like when the drug names are too long to fit in and the sigs [drug directions] are too long to fit in too…That’s a potential for our error because try to remember what you saw. Who wants to fill a prescription based on memory? That’s not safe…Are you going to remember it correctly? That’s an opportunity for error for sure.”
Performing mental calculations	“The quantity they are looking for is 120 units. In other words 2 boxes of 60… If it’s 3 mL each then 12 times 5 is 60. Ours then is 360, because we are going by the number of milliliters. So this is actually 2 boxes.”
Communicating with prescribers	“It’s less about ‘I can’t read what this is. What is it?’ but it’s more just, ‘Are you sure this is what you [prescriber] meant?’ So it’s really focusing more on clarification of what they [prescriber] intended, rather than trying to decipher what they actually wrote.” “There is another concern in that it doesn’t always print the information of the doctor where they’re currently at. If you have a doctor working a walk-in or an E.R. [emergency room] and you get a prescription from them, it sometimes lists their office phone number. Then if you have a question on it and you try to call the phone number that’s on the e-prescription sometimes they’re like, ‘Oh, well they’re not here today.’ Then you have to call around or they have to bounce you around from person to person until you can find where they actually are practicing. So it makes it harder to track them down.
Communicating with patients	“I can see part of it. If they’re giving you [paper] prescriptions, you know they’ve given you three prescriptions. If they say, ‘Oh, the doctor just sent down an e-prescription for me,’ Okay, well did they send down one prescription or did they send down four prescriptions? Sometimes patients know and sometimes they don’t. Even just for telling them a time of how long it’s going to take, if I can see they have three prescriptions here, in my mind I can do that. Whereas with e-prescriptions I’m not entirely sure how many have come down, so I say, ‘Oh, yeah, it will be ten minutes,’ because I thought it was one prescription, but ‘Oh, wait there are four prescriptions. Okay, it’s going to be 20 minutes now.’ “A lot of times when a patient comes down, they expect the prescription to be ready already because it was sent down electronically. Whereas when they bring it in with a paper prescription, they know that this is where it starts, right there. With an e-prescription it started 20 minutes ago, when the doctor sent it down. ‘I’m here to pick up a prescription.’ That’s how they come in. ‘Well, did you call it in or did the doctor send it?’ ‘The doctor sent it. It was 10 minutes ago.’ …That doesn’t take in to account the fact that three other doctors also sent prescriptions down all at the same time, so we’ve got four people coming down all for prescriptions at the same time, that all think they’re the only one. Then you’ve got four people waiting all of the sudden.”
Communicating in the pharmacy	“There is more potential to break HIPAA [U.S. Health Insurance Portability and Accountability Act, a legislative act that protects patients’ health information]. Because we have a small pharmacy, I’ll be over here [pointing to opposite side of pharmacy] and I’ll say, ‘Hey, can you pull a prescription for [John Doe],’ or whomever the patient may be. I’ll say it across the pharmacy, so the other patients know who the person is. Whereas with the paper prescription, it’s there and you don’t even have to say anything.”
Interruptions	“Sometimes when you are doing e-prescriptions you have to stop if someone comes to the window or they ask for something else, you know… if I got half way through the prescription and checking stuff. I won’t process it. I will just exit out of it and have to start all over”