Medication management process consists of five stages; prescribing, transmitting or transcribing, dispensing, administration and monitoring. I believe unintended consequences could occur anywhere in the process at any phase. However, after looking into the literature, I would agree that the most common phases where unintended consequences occur are prescribing, dispensing and administration.
For example, if the physician would select the patient’s name from a drop down menu or a search box, the physician could easily choose the wrong name. This would cause confusion and frustration between the pharmacist, patient and physician. In addition, if it was at a mail-order pharmacy setting, the patient would receive incorrect medication that could cause further complications or new onset of diseases, depending on that person’s condition. Furthermore, some systems could receive electronic and handwritten prescriptions. With illegible handwritten prescriptions, the pharmacist can mistakenly dispense a different medication that could be potentially fatal. Similar situation could happen if a physician chooses drug(s) from a drop-down menu, since drug names are sorted alphabetically and some drug names look the same, an incorrect drug could be selected. Depending on the system, if the pharmacist has no access to the patient’s medical history and/or diagnosis, there is no way for the pharmacist to intercept the error. It is important to incorporate updated patient data, medical history and demographics into the system; without these data calculating doses are going to be inaccurate.