Table 3. Excerpt of completed SHERPA table detailing output for sub-tasks 5.1 to 5.6.
| Task step | Type of task step | Error Code | Description | Consequence | Recovery | Probability of Error Occurring | Criticality of Error if Occurred | Remedial measures |
|---|---|---|---|---|---|---|---|---|
| 5.1 | Action | A8 | Prescriptions not removed from basket | No thorough checking of all prescriptions | H | L | Dedicated clear area for checking the prescription | |
| Operating procedure on how to organise medicines once dispensed in a basket | ||||||||
| Clearly marked number of prescriptions on each prescription (i.e., 1 of X) | ||||||||
| Anthropometrically appropriate desk for the pharmacist | ||||||||
| Consideration for colour contrasting (e.g., avoiding a white prescription in white basket on a white desk) | ||||||||
| A9 | Not all prescriptions removed from basket | No thorough checking of all prescriptions | H | L | Ensure correct size of baskets available and used depending on number of dispensed items | |||
| 5.2 | Check | C1 | No confirmation that all prescriptions belong to same patient | Medicines for more than one patient combined in one bag | 5.6 | L | M | Clear checking area with enough space to thoroughly check prescription |
| C2 | Incomplete confirmation that all prescriptions belong to same patient | Medicines for more than one patient combined in one bag | 5.6 | L | M | Reduced distractions and interruptions while dispensing | ||
| 5.3 | Action | A6 | Incorrect medicines are removed from basket | No thorough checking of all medicines | M | L | Operating procedure on importance of being thorough when checking medicines | |
| A8 | Medicines not removed from basket and placed next to relevant prescription | No thorough checking of all medicines | M | L | Clear checking area with ergonomically informed decisions on equipment used | |||
| A9 | Not all medicines are removed from basket and placed next to relevant prescription | No thorough checking of all medicines | M | L | ||||
| 5.4.1 | Check | C1 | No check for interactions between medicines | Interaction between medicines can have varied severity | L | L | Importance of clinical checks by pharmacist when checking prescription (e.g., posters on wall) | |
| Think about splitting the tasks of clinical and accuracy check | ||||||||
| Incorporate technology to aid the task (i.e., check at the computer) | ||||||||
| Forced break/task-switching policy to reduce possibility of unfocused checking | ||||||||
| C2 | Incomplete check for interactions between medicines | Interaction between medicines can have varied severity | L | L | Greater awareness of abilities and importance of task switching when unfocused | |||
| 5.4.2.1 | Check | C1 | No check for patient’s age | Unsuitable medicine for age | L | M | Introduce sticker for prescriptions belonging to young children to ensure their prescriptions are highlighted | |
| C2 | Incomplete check for patient’s age | Unsuitable medicine for age | L | M | ||||
| 5.4.2.2 | Check | C1 | No check for suitability of strength of medicine | Unsuitable medicine for age | L | M | Introduce sticker for prescriptions belonging to young children to ensure their prescriptions are highlighted | |
| C2 | Incomplete check for suitability of strength of medicine | Unsuitable medicine for age | L | M | ||||
| 5.4.2.3 | Check | C1 | No referring to reference material | Unsuitable medicine for age | L | M | Ensure reference material on site and to hand during checking task | |
| C2 | Insufficient referring to reference material | Unsuitable medicine for age | L | M | ||||
| 5.5.1.1 | Check | C1 | Failure to check medicine name | Wrong medicine dispensed | L | H | Clear area for thorough checking of prescription | |
| Explore ergonomic issues (e.g., font, size, tall-man lettering) | ||||||||
| C2 | Failure to completely check medicines name | Wrong medicine dispensed | L | H | Utilise bar code scanning to check medicines name | |||
| 5.5.1.2 | Check | C1 | Failure to check medicine strength | Wrong medicine dispensed | L | M-H | Clear area for thorough checking of prescription | |
| Standardised strength format (e.g., percentages or strength)—same as prescription | ||||||||
| Introduce colour coding as a supplementary cue for different strengths | ||||||||
| C2 | Failure to completely check medicines strength | Wrong medicine dispensed | L | M-H | Isolate high-risk drugs with high potential for error (e.g., Methotrexate 2.5mg or 10mg) | |||
| 5.5.1.3 | Check | C1 | Failure to check medicine quantity | Wrong amount of medicine dispensed | L | L | Clear area for thorough checking of prescription | |
| C2 | Failure to completely check medicine quantity | Wrong amount of medicine dispensed | M | L | Ensure pack sizes are consistent (e.g., Clopidogrel 28 and 30 tablets) | |||
| 5.5.2.1 | Check | C1 | Failure to check patient name compared to label | Wrong patient’s medicine dispensed | L | L | Clear area for thorough checking of prescription | |
| Clear up patient profile names | ||||||||
| 5.5.2.2 | Check | C1 | Failure to check medicine dose compared to prescription | Wrong dose printed on label | L | M | Clear area for thorough checking of prescription | |
| Standardised dosing names | ||||||||
| 5.5.3 | Check | C1 | Failure to check medicine expiry date | Expired medicines dispensed | M | L | Clear process for checking medicines | |
| Regular data checking process | ||||||||
| Mark medicines that are expiring within 6 months | ||||||||
| Procedure for checking medicine expiry dates on receipt of stock into the pharmacy | ||||||||
| Ensure expiry dates written on split pack box | ||||||||
| Ensure date opened documented on medicine | ||||||||
| Use bar code scanning to ensure medicines in date | ||||||||
| 5.5.4 | Check | C1 | Failure to check medicine related issues | Item related medicine issue failure | M | M | Importance for training on specific items | |
| Sticker for fridge and CD medicines | ||||||||
| C2 | Failure to completely check medicine related issues | Item related medicines issue failure | M | M | Importance for training on specific items | |||
| 5.6 | Check | C1 | Failure to check bag label | Wrong bag label on bag | M | H | Clear organised area | |
| Stick bag label on basket | ||||||||
| Introduce record of dispensing register | ||||||||
| Ensure clear audit trail of who dispensed, accuracy checked, clinically checked, and handed out the prescription |
P = Probability of Error Occurring, C = Criticality of Error if Occurred, H = High, M = Medium, L = Low. Refer to Table 2 for error code descriptions.