Case Study Dr. Monroe filled out a written prescription and handed it to his Medical Asst. to give to Mr. Smith his patient who was being discharged. The MA who noted the doctor's signature was not on the prescription handed it to the front office clerk stating she needed to have the doctor sign the prescription. The MA went about her duties and forgot about the prescription and was subsequently allowed to go on lunch. The front office clerk was relieved to go to lunch by practice manager but forgot to mention to the manager Mr. Smith was waiting for his Rx. Mr. Smith, after waiting in the lobby, approached the practice manager at the desk and asked for his Rx. The practice manager handed the written prescription to Mr. Smith without noting the lack of the Doctor's signature on the prescription. Mr. Smith placed the prescription in his coat pocket and traveled to the pharmacy. Upon arrival to the pharmacy Mr. Smith handed the Rx to the clerk who indicated the Rx would be filled in 2 hours and return to pick it up. The pharmacy clerk reviewed the Rx and noted the doctor had forgotten to sign the prescription. The pharmacy clerk called the office and left a message for the Dr. to call the pharmacy as his Rx lacked his signature. Dr. Smith returned the pharmacy phone call 6 hours later. During the 6-hour window Mr. Monroe had already returned to the pharmacy and was told his prescription was not ready and to return in 4 hours to pick up the prescription. Mr. Smith returned and picked up his prescription 8 hours after dropping of the prescription initially. The benchmarked for dispensing filled prescriptions to patients is 2 hours. The prescription fill time for Mr. Smith was over 8 hours. The pharmacy leadership tracks prescription refills as part of their quality improvement program and wants to understand how to improve their processes. They have asked you to investigate the delay in filling the prescription. As part of your process analysis, you will utilize a fishbone diagram to represent all the processes that contributed to the delay in the prescription being filled.