Table 4

High-risk industry failures and potential solutions

Failure	Effect	H	Causes	F	D	CI	RPN
High-risk industry level
Diabetes education does not highlight similarity in insulin pens (eg, colour of rapid-acting vs long-acting pen); patient does not remember or realise the difference	Wrong insulin pen used; incorrect dose; incorrect type of insulin Patient experiences symptomatic hypoglycaemia (≤70 mg/dL) or symptomatic hyperglycaemia (250–349 mg/dL)	7	Medication use Similarity of insulin pens Patient education Variation in training by endocrinology/diabetes providers/educators in addressing the similarities of pens Not all pens are available for inpatient teaching; potential failure not detected	10	9	70	630
Containment solution: Instructions highlighting the design similarities of insulin pens during education Permanent solution: Add provision to FDA approval mechanism (release to market approval) for improved differentiation of pens (type/design)
Contradicting DM medication instructions in different sections of discharge instructions	DM postdischarge medication error leading to symptomatic hypoglycaemia (≤70 mg/dL) or symptomatic hyperglycaemia (250–349 mg/dL)	7	Healthcare information technology, Leadership Lack of integration of discharge instructions from multiple care teams, specifically for high-risk medications Automated discharge medication list does not provide accurate discharge instructions Human factors and communication Transcription error when discharge instructions are manually integrated Complexity of instructions	10	8	70	560
Containment solutions: Primary inpatient service/team or pharmacist integrates medication discharge instructions and removes duplicate, conflicting entries Create an EHR ‘work around’ to permit flexibility of high-risk medication (eg, insulin) discharge instructions Permanent solution: Use of user (provider/patient) centred design methods in creation of electronic health record software for discharge instructions for high-risk medications such as insulin
Lack of/incorrect verification of whether DM medication(s) and supplies are covered by patient’s insurance	Prescriptions/supplies not covered by insurance; patient experiences symptomatic hyperglycaemia (250–349 mg/dL) Delay in patient being able to fill prescription and taking DM medication	7	Information management Lack of a system where providers can easily verify patient coverage and patient-specific out-of-pocket payments to enable shared decision-making	10	2	70	140
Containment solution: Provide patient with samples of covered pharmaceutical supplies or medications prior to discharge Permanent solution: Automated EHR function that verifies insurance coverage of prescribed medications and/or supplies

CI, Criticality Index; D, detection; DM, diabetes mellitus; EHR, electronic health record; F, frequency; FDA, Food and Drug Administration; H, harm; RPN, Risk Priority Number.