Risk Assessment: Tools, Techniques, and Their Applications

22.1 Case Study 1: Overview

Pharmacy robot (PR) is owned by a pharmaceutical company and is leased by the local hospital. This is the only pharmacy in the state to implement the robotic technology in their everyday care of patients. The technology includes the physician writing the drug order in triplicate and the pharmacist reads, interprets, and enters the drug order into the software program that the PR reads. PR uses infrared lights to read the bar code of each drug and fills the patient's drugs for a 24-h period. PR fills 112,000–115,000 prescription orders per month. The robots error rating for picking and filling is zero; however, at the hospital, there are 15–20 documented miss picks per month. These errors are found to be human error in packaging processes and are corrected when the pharmacist makes his check. Some errors occur by the nurse dispensing the wrong drug to the wrong patient; these errors are few and will hopefully be eliminated when the nurse servers are installed later this year. Records indicate that before using PR, error rates for dispensing and distributing drugs were much higher.

22.1.1 Introduction

Our risk assessment class at the University of Idaho performed an analysis of PR, the robotic prescription delivery system and the soon to be used nurse servers, all in service at our local hospital. Figures 22.1 and 22.2 show the components of the robot. PR is a complex system that fills an area of about 600 ft². Figure 22.3 shows typical, unitized doses ...