Table 7.

Significant failure modes result in MEs.

Failure modes	Causes	Effects
Medication orders' confirmation
F 1: unable to verify medication orders	Absence of proper electronic health record (EHR).	Unable to know the dose that was given before.
Print medication list from electronic record
F 2: inaccessibility to EHR	Busy timetable, inappropriate communication.	Extra dose given.
Getting medication from pharmacy
F 3: mislabeling and incorrect medication dispensed in shelves in pharmacy	Misreading labels and incorrect stock of medications in pharmacy.	Giving incorrect medication, incorrect dose, or spending more time for giving the correct medication.
F 4: unable to verify the correctness of given dose	Absence of supporting documentation to prove if patient received the dose before.	Incorrect medication administration.
Scan patient identification (ID) numbers
F 5: assigning incorrect ID number to patient	ID band is not scanned.	Medications might be administered to the wrong patient.
F 6: inappropriate scanning	Busy timetable, lack of knowledge about medication administration.	Incorrect medication administration
Scan medication barcode and administrate
F 7: wrong medication or wrong time of administration process in pharmacy.	Mislabeling in pharmacy or physician changes the medication order.	Patient may not take the correct medication or receive medication at the right time.
F 8: medication may be administered incorrectly via wrong route or dosage.	Wrongly reading order. Unfamiliarity with medicine.	The patient is negatively affected through incorrect route of medication.
F 9: system overriding by manually entering medication barcode of medicines' containers.	Mislabeling of container. System malfunction.	Receiving the wrong medication, dose, or medication administration.
Prepare medications
F 10: medications may be prepared wrongly.	Incomprehensible medication label or physician order.	Patient may receive the incorrect dosage of medication or take the medication via the wrong route.
Incorrect dosage or incorrect route.	Not double-checking order previous to preparation.