Table 1

Failure modes for chemotherapy administered via ambulatory infusion pumps

CategoryFailure modeSeverityProbability
Pump-programming errorNurse enters incorrect rate when programming pumpCatastrophicOccasional
Nurse enters incorrect volume when programming pumpMinorOccasional
Nurse enters incorrect lock level (or forgets to lock) when programming pumpMinorOccasional
Patient-identification errorNurse picks up medications from pharmacy and administers to wrong patientCatastrophicOccasional
Mismatch between drug label and orderPrepared medication does not match order because physician has changed order since pharmacy printed it and prepared the medicationModerateFrequent
Prepared medication does not match order because pharmacy made error when transcribing the order into pharmacy systemCatastrophicOccasional
Clinical decision errorPhysician 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.CatastrophicUncommon