Patient Provider Policy

Expectation of complete/correct Document Issue

prescription
Incomplete
Documentation Compliance with standards
Language Barrier
Attention to sign Rx
Lack of awareness
Lack of Time
Lack of availability/
Lack of Education Accessibility

Lack of enforcement
Distracted by discomfort/pain

Rx Fill
No Follow Up
with Patient
Heavy Patient
Volume
Multiple Handoffs
Delay
Lack of Supervision/
No Follow Up with Lack of Training Management
Prescriber
Inexperienced
Poor Patient Nurses/Clerks/Techs
Lack of Tracking
Training Ineffective No Communication
Communication

Incomplete Rx Awareness of missing

information Unsigned Rx

Pharmacy Organization Staff

Problem Statement:
A patient was discharged with an unsigned prescription making it invalid and was repeatedly
handed off through several staff members at clinic and pharmacy causing an 8-hour delay in
filling a prescription for a patient. Staff members including provider, nurses, clerks, management
and pharmacy technicians contributed to lack of correct processes needed to fill a prescription
within the time given by quality metrics. The diagram above depicts key items that must be
addressed to achieve the benchmarked time to fill prescriptions of 2 hours. Causes like lack of
communication, training and heavy workload are presented more than once in the diagram
making these items a priority to correct.