Table 1 List of Scenarios Identified in Stage 1 and Results from Stage 3
Category 1: Electronic-prescribing (Technology Generated) | ||||||
Scenario | Scores (Median, IQRa) | Outcome | ||||
Rdc 1 | Rd 2 | Rd 3 | Consensus | Error | ||
1 | Alteration of a standard order from a dropdown menu resulting in incongruous supplementary instructions | 7 (4) | 7 (1.5) | x | ✓ | ✓ |
2 | Alteration of an existing order resulting in incorrect supplementary instructions | 7 (4) | 7 (2) | x | Partial | ✓ |
3 | Selection of an incorrect formulation (caused by failure to amend default formulation) | 7 (4) | 7 (4) | 7 (1.8) | ✓ | ✓ |
4 | Inappropriate completion of ‘Max Dose’ field (removing autofilled dose on MARd, causing potential to administer doses outside dose/weight limits) | 6 (5) | 6 (4) | 6 (3.8) | Partial | Equivocal |
5 | Medication (Infusion Order) not cancelled 48–72 h after written and not used e.g. Inotropes on Order Set | 4 (5) | 4 (2) | x | Partial | ✕ |
6 | Medication (Infusion Order) not cancelled 48–72 h after infusion discontinued | 4 (5) | 4 (4) | x | Partial | ✕ |
7 | Prescription duplication | 8 (3) | 8 (2) | x | ✓ | ✓ |
Category 2: SMART-PUMPS (Technology Generated) | ||||||
Scenario | Scores (Median, IQRa) | Outcome | ||||
Rdc 1 | Rd 2 | Rd 3 | Consensus | Error | ||
8 | Wrong patient weight programmed | 9 (0) | x | x | ✓ | ✓ |
9 | Wrong drug programmed from drug library | 9 (0) | x | x | ✓ | ✓ |
10 | Wrong rate programmed | 9 (0) | x | x | ✓ | ✓ |
11 | Incorrect SCIb programmed (not equal to SCI ordered or prepared) – incorrect dose administered | 9 (0) | x | x | ✓ | ✓ |
12 | Incorrect SCI prepared (pump programmed with SCI ordered rather than SCI prepared)-incorrect dose administered | 9 (0) | x | x | ✓ | ✓ |
13 | Programmed as per SCI in syringe but pump assigned to incorrect electronic infusion order (resulting in incorrect auto-charting of dose administered) | 9 (1) | x | x | ✓ | ✓ |
Category 3: Prescribing of PICU Infusions | ||||||
Scenario | Scores (Median, IQRa) | Outcome | ||||
Rdc 1 | Rd 2 | Rd 3 | Consensus | Error | ||
14 | Ordering an infusion in the wrong concentration for a patient without valid clinical rationale | 9 (1) | x | x | ✓ | ✓ |
15 | Writing an incorrect statement of rate (type A): expressing rate as X ml (rather than Xml/hour) = dose/weight/time | 8 (2) | x | x | ✓ | ✓ |
16 | Writing an incorrect statement of rate (type B): expressing rate using incorrect unit of time e.g. ‘per min’ instead of ‘per hour’ | 9 (1) | x | x | ✓ | ✓ |
17 | Writing an incorrect statement of rate: Combination of both type A and type B error | 9 (1) | x | x | ✓ | ✓ |