Table 1

Failure modes for chemotherapy administered via ambulatory infusion pumps

Category	Failure mode	Severity	Probability
Pump-programming error	Nurse enters incorrect rate when programming pump	Catastrophic	Occasional
	Nurse enters incorrect volume when programming pump	Minor	Occasional
	Nurse enters incorrect lock level (or forgets to lock) when programming pump	Minor	Occasional
Patient-identification error	Nurse picks up medications from pharmacy and administers to wrong patient	Catastrophic	Occasional
Mismatch between drug label and order	Prepared medication does not match order because physician has changed order since pharmacy printed it and prepared the medication	Moderate	Frequent
Mismatch between drug label and order	Prepared medication does not match order because pharmacy made error when transcribing the order into pharmacy system	Catastrophic	Occasional
Clinical decision error	Physician orders an inappropriate prescription, and this is not detected by subsequent care providers. Error could be with any aspect of the drug order: dose weight (mg), dose volume (ml), infusion rate, infusion volume, etc.	Catastrophic	Uncommon