Table 2.

Failure modes with their causes, mitigation measures and criticality index (CI) scores for intensive care unit (ICU)

Step	Failure modes	Cause(s)	Hospital relocation				Evacuations
			Mitigation measures	CIa	CIb	∆	Mitigation measures	CIa	CIb	∆
Transport	No treatment available due to contextual pathology during transport	Contextual pathology (eg, fractures, burns)					AMP Vital medications, antidotes and emergency drugs bags Emergency evacuation kit	810	225	−72%
	No treatment during transfer due to lack of medication	Logistical and communication issues	Checklist (Medication handling, Medical examination, Tracking and transmission sections) Specific medication transported with the patient, tracked and sealed Transmission protocol	162	18	−89%	AMP Vital medications, antidotes and emergency drugs bags Emergency evacuation kit	486	225	−54%
	Medication administration during the transfer not correctly tracked	Human error, lack of communication	Checklist (Medication handling, Tracking and transmission sections) Transmission protocol	160	20	−88%	Vital medications, antidotes and emergency drug bags Emergency evacuation kit	441	225	−49%
	Batteries not charged, not enough equipment, lack of oxygen	Logistical issues	Checklist (Tracking and transmission sections)	135	9	−93%
Hospital B (installation at new site)	Patient transported to the wrong place	Communication issues					Tracking patient ID and localization Degraded mode available Transmission protocol	560	252	−55%
	Double-dose or medication not administered	Lack of medication traceability	Checklist (Medication handling, Tracking and transmission sections)	175	28	−84%
	Impossibility of providing treatment due to incompatible administration equipment	Lack of training and compatibility issues	Reanimation team available Specific transport team given the initial triage assigned Transmission protocol	343	105	−69%
	Impossibility of accessing the required medication	Lack of medication (no stock of the drug in the hospital), delivery/order issues	Checklist (Medication handling, Medical examination, Tracking and transmission sections) Specific medication transported with the patient, tracked and sealed Transmission protocol Prescription verified by pharmacy technician Automated medication dispensing system	175	28	−84%	AMP Vital medications, antidotes and emergency drugs bags Emergency evacuation kit	810	225	−72%
Global	Patient feeling unwell during intra-hospital transfer, but no qualified HCPs present to assist	Lack of qualified staff	Transmission protocol Checklist (Medication handling, Medical examination, Tracking and transmission sections) Vital medication is available at all times Triage algorithm Reanimation team available Specific transport team	216	32	−85%	AMP Vital medications, antidotes, and emergency drugs bags Emergency evacuation kit Emergency call-back mode	567	378	−33%
	Impossibility of correctly ensuring delivery of patient’s medication in the contextual environment	Too high workload (transfer, new admissions, not enough staff)	Transmission protocol Checklist (Medication handling, Medical examination, Tracking and transmission sections) Vital medication available at all times Triage algorithm Reanimation team available Specific transport team given the initial triage assigned	120	20	−83%	AMP Vital medications, antidotes and emergency drugs bags Emergency evacuation kit Emergency call-back mode	630	294	−53%
	Loss of information about the patient’s treatment/medication	Communication issues	Transmission protocol Checklist (Medication handling section) Patient’s information (informatic folder or degraded mode)	320	120	−63%	Emergency evacuation kit	560	252	−55%
Mean				201	49	−76%		592	282	−52%

AMP, Advanced Medical Post; HCPs, Healthcare professionals; ID, Identity.