limited space & small counter

no baskets for segregation of each patient

one person allocate, pick pack & deliver

unable to follow SOP of having double checker during dispensing

not following SOP - no double checking against prescription prior to dispensing

card & medication put next to each other on table- risk of mix up

limitation of Bru-Hims- small font size label

Bru-HIMS not user friendly- have to switch screen multiple times because of the processes (allocate & deliver)

rushing to clear patients

non stop patients- busy

a lot of distractions from patients asking questions- where to put cards etc even though label instructions are provided

peak hour- patients can go up to 100 plus patients with over 300 items in second shift

one person manning ED pharmacy per shift

staff tired- working in shifts & one shift is 7.5 hrs without breaks (breaks only taken when it is less busy)

human error