Failure point (taken from the HTA) | Example of active failure | Type of task step | Likely contributing factors | Recovery step | Potential mitigation strategies | |
Slips and lapses | 3.2–3.4 | Failure to document prescription details appropriately. | Information entry and communication. | Cognitive burden; memory processing; workload and prioritisation; and support. | Nursing staff will not administer medication without a complete prescription. | Computerised physician order entry and standardised order sets. |
3.7 and 3.8 | Failure to document times for administration. | |||||
3.10 | Failure to sign the prescription. | Information entry. | ||||
Rules-based mistakes | 3.5.1–3.5.4 | Failure to undertake pre-prescription checks (physiology, organ status, other meds and route). | Planning; information retrieval; and information interpretation. | Skills and knowledge; complexity; and verbal communication. | Pharmacist review of medication. | Computerised Decision Support Systems (CDSS). |
3.7 | Select incorrect dosing frequency/times. | Selection; information retrieval; and information entry. | Skills and knowledge; complexity; verbal communication; and ambiguous information. | Nursing staff will not administer medication if frequency is incorrect. | Standardised order sets. | |
3.5.4.2–3.5.4.4 | Incorrect calculation; wrong final infusion volume/concentration; and wrong infusion rate. | Information retrieval; information entry; and calculation. | Cognitive burden; skills and knowledge; inexperience; verbal communication; ambiguous information; and divergent practice. | Nursing staff will not administer medication if infusion prescription is incorrect. | Organisationally standardised infusion concentrations and prescriptions. | |
Knowledge-based mistakes | 3.1 | Incorrect action taken based on faulty analysis of different drug dosing references. | Information retrieval; communication; and information interpretation. | Verbal communication; ambiguous information; skills and knowledge; and divergent practice. | Nursing staff will not administer medication if dosing reference is ambiguous. | Standardised formularies. |
3.5.1 | Failure to take account of interactions (drug/disease), effects of fluid restriction, impact of route of administration and age/weight. | Information retrieval and information interpretation. | Verbal communication; ambiguous information; and skills and knowledge. | None. | CDSS. | |
3.5.4.3 | Wrong final infusion volume/concentration. | Information retrieval; information entry; and calculation. | Cognitive burden; ambiguous information; skills and knowledge; inexperience; and divergent practice. | Nursing staff will not administer medication if infusion prescription is incorrect. | Organisationally standardised infusion concentrations and prescriptions. | |
3.9.2 | Failure to identify monitoring conditions. | Planning; communication; and information entry. | Ambiguous information; skills and knowledge; and inexperience. | Nursing staff will challenge monitoring requirements. | CDSS. |