“Failure mode analysis” would involve a detailed critical analysis as to which sub process went wrong and then doing the “failure mode cause analysis” of the sub process to locate the element responsible for it, such as:
1. Mistakes in Prescribing the Medication:
The doctor’s orders may be verbal or written. Verbal orders are prone to be misunderstood. Written orders, too, could be the cause of errors. There may be mistakes in writing the name of the drug, the dosage, the route, and the frequency of administration or the precautions to be taken.
2. Mistakes in Interpreting the Prescription:
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The doctor’s handwriting may not be legible. The sister may decipher it incorrectly, particularly if she is not an experienced nurse.
3. Mistakes in Noting down the Orders:
There may be a mistake by the sister in writing down the orders on the nurse’s record or the nurse’s work book.
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4. Mistakes in Drug Identification:
While getting the drug ready, the nurse can make a mistake and take out the wrong drug (sound alike, look alike drug), the wrong strength or the wrong route drug (intramuscular instead of intravenous).
5. Failure to Identify the Correct Patient:
The nurse may fail to correctly identify the patient. It may be the wrong bed or the room. She may fail to check the patient’s name, the CR number or the ID band.
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The hospital may not be having the system of using ID band, or the band may not have been fixed on that patient or may have been fixed at the wrong place on the body of the patient.
6. Mistakes in Medication Administration:
Administration of drug to the patient may be faulty. The nurse may fail to check/test for allergy to the drug or may prepare the drug in the wrong strength.
She may administer the drug at the wrong time, in the wrong dose, by the wrong route. The nurse may fail to brief the patient about the signs of adverse effects and may fail to caution him/her about it.
7. Failure to Observe for Adverse Effects:
The nurse may fail to observe the patient after administering the drug. She may get busy with other patients.
8. Delay in Detecting the Problem:
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There may be a delay in nurse’s response to the patient’s complaint of symptoms. The nurse may fail to realize that wrong drug has been administered to the patient or may fail to realize that the patient has developed adverse effects of the drug administered.
9. Delay in Response:
The counter measures by the nurse may be delayed or inadequate. The ward may not be having all the requisite equipment, the anaphylactic tray may not be ready or the oxygen cylinder may be empty.
The doctor’s phone may be busy or he may not be readily available to respond to the emergency call.