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. Author manuscript; available in PMC: 2011 Aug 1.
Published in final edited form as: Jt Comm J Qual Patient Saf. 2010 Aug;36(8):376–384. doi: 10.1016/s1553-7250(10)36056-9

Figure 1. Failure Modes Sorted by Step of the Medication Management Process and by Criticality.

Figure 1

The figure shows how the most critical failure modes can be sorted by step of the medication management process or for the entire process. Criticality (likelihood × impact on patient × impact on registered nurse) ranges from 1.75 for failure mode C12 (family refuses to medication [patient unconscious/unable to make decisions] to 21 for failure mode C9 (IV pump malfunctioning). IV, intravenous; RN, registered nurse; ID, identification; MAR, medication administration record; ICU, intensive care unit.