Figure 2.

A simple process map representing how drugs are ordered, dispensed and administered in our imaginary Newborn Unit (NBU). Key initial actors (left of figure) include the pharmacist, nurse 1 who collects the drugs and nurse 2 who later gives the first dose of drug. In our example, the process involved a sequence of activities (rectangular boxes connected by unbroken arrows) that took place without any active checking or decision-making steps. We have added potential decision-making or checking steps that would create a new pathway (illustrated by the diamonds and the broken arrows) that six points at which a drug error (panel 1) might have been averted or detected. In our example, as it was not a routine practice to check drug vials for the preparation they contained the drug error was repeated over several days (by nurses 3, 4 and 5).