Table 3.

High-risk failure-modes identified across multiple medication use failure mode and effect analysis

High-risk failure modes	Process phases	NICU	PICU	Acute care	Onco-haematology	General Ped	N° High-Risk Failure Modes
Error in using the Kanban system for re-order drugs	Supplying					▪	1
Failure to check pharmacy supplies (to cross-check drugs ordered against drugs delivered and to correlate the drug package with the patient)	Supplying					▪	3
Error in calculating the dosage of medication (Failure to measure patient's weight and height, failure to correctly prescribe bolus and continuous infusion drugs, ‘high-risk’ intravenous drugs, dilutions, infusion rate, frequency of administration)	Prescription	▪	▪	▪	▪	▪	8
Failure to check dose and frequency of administration	Prescription	▪	▪	▪	▪		4
Erroneous prescription of therapy on the order form (writing error and transcription error on a new therapy form, oral prescription over the phone during the night)	Prescription		▪	▪	▪		3
Incomplete reassessment of the daily clinical status and lack of written notes and/or spoken information on changes in clinical situation	Prescription	▪					2
Failure to notify to the nurse a new medication order (either for bolus or and infusion, for changes and end of infusion)	Prescription	▪	▪				4
Failure to check chemotherapy components	Prescription				▪		1
Unavailability of drugs at the time of patient's transfer owing to lack of medication reconciliation, and urgent need for drugs from the pharmacy	Prescription				▪		1
Misinterpretation of prescription by the nurse owing to illegible handwriting or shortcuts	Prescription			▪	▪	▪	3
Failure to consult handbook to check proper dilution, concentration, compatibility, rate of administration, photosensitivity and method of administration	Preparation	▪					2
Erroneous calculation of the prescribed dose of medication (incorrect choice of proportions to obtain the right dose in ml, or of the proportions needed to reach the maximum concentration of the drug)	Preparation	▪		▪			1
Failure to identify type of drug in syringe during infusion and before storing it in the refrigerator	Preparation	▪	▪				2
Failure to explain to parents how to monitor the drug's administration	Administering					▪	2
Inadequate monitoring of potential adverse effects	Monitoring			▪			1
Total high-risk failure modes		8	8	9	6	6	37

General Ped, general paediatric ward; NICU, neonatal intensive care unit; PICU, paediatric intensive care unit.

▪, Error was found in the unit selected