Human Factors in Healthcare 2 (2022) 100030

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Human Factors in Healthcare

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Original Article

Medication safety for intensive care patients transferring to a hospital

ward: A Hierarchical Task Analysis
Richard S Bourne a,b,∗, Denham L Phipps b, Jennifer K Jennings a, Emma Boxall c, Franki Wilson d,
Helen March e, Darren M Ashcroft b,f
a
Departments of Pharmacy and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
b
Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC),
The University of Manchester, Manchester, UK
c
Pharmacy Department, Salford Royal Hospital, Northern Care Alliance NHS Group, Salford, UK
d
Pharmacy Department, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
e
Pharmacy Department, Royal Oldham Hospital, Northern Care Alliance NHS Group, Oldham, UK
f
National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre (PSTRC), School of Health Sciences, Faculty
of Biology, Medicine and Health, The University of Manchester, Manchester, UK

a r t i c l e i n f o a b s t r a c t

Keywords: Aims and objectives: To identify the task steps involved in intensive care patients transferring to a hospital ward
Critical care and their potential for human errors, and to prioritise areas to improve medication safety.
Ergonomics Background: Intensive care patients recovering to transfer to a hospital ward experience challenges to care con-
Medication errors
tinuity and safety, including medication safety. Medication errors are common on this interface of patient care,
Patient safety
contributing to the risk of adverse drug events on the hospital ward and beyond. Human factors are an important
consideration in these transfer-related medication errors.
Methods: A hierarchical task analysis, based on a goal of safe continuity of medication for intensive care patients
on transfer to a hospital ward, was developed from local processes taken from four north of England hospital
Trusts with electronic prescribing systems. The task analysis was developed and refined by the research team,
incorporating documentary review of policies and procedures, and healthcare professional interviews. Failure
modes for the key task steps impacting directly on patient medication safety were identified. Finally, ten intensive
care healthcare professionals, individually graded each failure mode (1-5) in terms of the probability, criticality
and detectability. Median grades for each parameter were used to determine an overall clinical risk score for each
task step.
Results: Ten task steps were identified (one conditional), comprising a total of 56 subordinate task steps (two
conditional). Conditionality was based on integrated electronic prescribing system resource across the care in-
terface. Thirty-four of the 56 (61%) subordinate task steps were considered by the research team to specifically
involve medication continuity or safety aspects. Action omissions (operation, check, information communication)
accounted for failure modes in twenty-four of the 34 (71%) task steps. Most task steps (25/34 (74%)) had one
or more recovery steps, providing further safety opportunities. The medication review task for reviewing and
re-introducing long-term medication had the highest cumulative risk score. The top six clinical risk scores for the
failure modes involved task steps with some element of communication around medicines.
Conclusions: The safe continuity of medication for intensive care patients on transfer to a hospital ward is complex
and prone to human error. Failure mode analysis indicated that medication review on intensive care prior to
patient transfer, and communication around medication changes and plans, are particularly important risks that
require addressing in any intervention developed to improve medication safety in this patient care transition.

Abbreviations: Electronic, e; ICU, Intensive Care Unit; HRA, Health Research Authority; HTA, hierarchical task analysis; NHS, National Health Service; SHERPA,
systematic human error reduction and prediction approach.
∗
Corresponding author.
E-mail address: richard.bourne1@nhs.net (R.S. Bourne).

https://doi.org/10.1016/j.hfh.2022.100030
Received 14 August 2022; Received in revised form 16 November 2022; Accepted 17 November 2022
2772-5014/© 2022 The Authors. Published by Elsevier Inc. on behalf of Human Factors and Ergonomics Society. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/)
R.S. Bourne, D.L. Phipps, J.K. Jennings et al.
Problem Statement
To address challenges to medication safety for intensive care pa-
tients transferring to a hospital ward, an evaluation of the human
factors involved is required to prioritise interventions designed to
improve patient care.
Introduction
Intensive care units (ICUs) provide urgent and dynamic care to some
of the most vulnerable patients in a hospital setting. Such patient care
is complex, requiring effective co-ordination of multiple healthcare pro-
fessionals and care teams, working in a technologically advanced and
time pressurised environment.
When patients recover sufficiently from their critical illness, transfer
to a lower acuity clinical area usually precedes hospital discharge. This
interface in patient care presents a challenge to patient care continu-
ity and safety. ICU patients frequently experience adverse events after
transfer to a hospital ward (Sauro et al., 2020). These adverse events in-
clude adverse drug events, potentially related to the high rates of med-
ication errors patients experience on transfer from ICU (Bosma et al.,
2018; Heselmans et al., 2015; Tully et al., 2019; Wang et al., 2022).
The reported clinical significance of these medication errors varies ac-
cording to study design. Prospective intervention studies,(Bosma et al.,
2018; Heselmans et al., 2015) reporting higher rates of potential patient
harm related to adverse drug events (25-38%), compared to retrospec-
tive cohort studies (Tully et al., 2019; Wang et al., 2022).
Although ICU care provision benefits from the use of many tech-
nological solutions, an over-reliance on technology to mitigate against
medication errors underestimates the complexity of the systems and pro-
cesses involved in medicines management, and the pivotal role that hu-
man factors play in this (Bueno et al., 2019; Manias et al., 2012; Scanlon
& Karsh, 2010). An example is the need for effective team collaboration
and communication (Donchin et al., 2003), to reduce the risk of errors
in ICU care; particularly important on patient transition from ICU to
the hospital ward (Stelfox et al., 2017; van Sluisveld et al., 2015). In
common with wider healthcare delivery, ICU and its care transitions
is dependent on a complex interaction of technology, tasks and peo-
ple (McNab et al., 2020). As such, there is an appreciation of the vi-
tal role human factors engineering has on ICU medication management
and patient safety pathways (Carayon et al., 2014; Donchin et al., 2003;
Scanlon & Karsh, 2010).
A hierarchical task analysis (HTA) is intended to provide a de-
tailed behavioural description for examining the actions or cogni-
tive processes involved in a given work activity (Stanton, 2006).
Task analysis has previously been used in several hospital settings
including; ICU,(Sutherland et al., 2019) anaesthesia,(Phipps et al.,
2008) emergency medicine,(Hayden et al., 2018) and in medicines
safety,(Lane et al., 2006; Sutherland et al., 2019) to identify human
factors issues affecting safety in clinical practice. The HTA is then en-
hanced by a systematic human error reduction and prediction approach
(SHERPA), that provides a taxonomy of errors to assist with the iden-
tification of the types of errors possible, the likely consequences, the
criticality, any recovery steps and design recommendations (Stanton &
Young, 2002).
The aim of this study was to identify the task steps involved in ICU
patients transferring to a hospital ward and their potential for human
errors, to prioritise areas to improve medication safety
Methods
Hierarchical Task Analysis (HTA)
HTA provides a systematic method allowing analysis of complex pro-
cesses in terms of the behaviours involved (Lane et al., 2006). The HTA
2
Human Factors in Healthcare 2 (2022) 100030
process starts with a defined goal, then identifies task steps required
to achieve that goal. Execution of the task steps is required to deliver
the subgoals, which in turn need to be achieved to realise the over-
all (defined) goal. The plan is the chronological order of these subgoal
steps.
The HTA was formed over several steps (Fig. 1). Firstly, the research
team, comprised of clinical subject experts and a human factors spe-
cialist (BBB), agreed the HTA goal. We then collated formalised ICU to
hospital ward medicines safety transfer guidelines, protocols and stan-
dardised operating procedures from four National Health Service (NHS)
hospital centres in the North of England. These NHS centres provided
a range of Teaching and non-Teaching hospitals and variations in elec-
tronic (e-) prescribing system integration between the ICU and hospital
ward. We used these procedures to provide the first iteration of the in-
dividual constituent task steps and that were required to achieve the
goal.
To supplement our documentary analysis, we reviewed the tran-
scripts of interviews with ICU and ward staff (medical staff, pharmacists,
advanced nurse practitioners and critical care outreach team members)
conducted for a previous study of inter-hospital transfers. More details
about this interview study are provided in a separate paper (Bourne
et al., manuscript under peer review in a health service journal); in
brief, the study explored healthcare staff views on medication safety
at this interface of care using a topic guide based on the Systems Engi-
neering Initiative for Patient Safety (SEIPS 3.0) model,(Carayon et al.,
2020) and London Protocol (Taylor-Adams & Vincent, 2004). The SEIPS
3.0 model is based on the System-Process-Outcome description inform-
ing quality of health care, including an expanded process component,
focusing on the patient pathway to describe patient interactions with
multiple care settings over time (Carayon et al., 2020). The London Pro-
tocol was developed from Reason’s accident causation model to capture
the contributing factors and context around specific patient safety inci-
dents and adverse events (Taylor-Adams & Vincent, 2004). The research
team used the information about the task process elicited by these inter-
views to ensure the HTA task steps included all key medication safety
steps identified by team discussion and consensus agreement. The draft
HTA was then sent to all healthcare professionals who had previously
participated in the interviews for respondent validation. After partici-
pant feedback and revision, the HTA was then finalised by the research
team.
Systematic Human Error Reduction and Prediction Approach (SHERPA)
We then extended the task analysis by performing SHERPA (Fig. 1).
The SHERPA provides a behaviour-related taxonomy to the completion
of each step (action; planning; evaluation; selection; checking; infor-
mation retrieval; information entry; information communication; and
calculation) (Stanton & Young, 2002). Firstly, the research team iden-
tified the key task steps with failure modes likely to impact directly on
patient medication safety. Next, representative views of the ICU mul-
tiprofessional interview participants (pharmacist, advanced nurse prac-
titioner, medical staff and outreach team member) from a single cen-
tre were sought. Working with the research team, they suggested er-
rors that may occur during task execution, before identifying the sin-
gle most likely task failure mode, related consequences, and any po-
tential recovery steps available within the HTA, as well as potential
remedial action to take. Finally, ten ICU healthcare professionals (4
pharmacists, 2 medical, 2 advanced nurse practitioners, 2 outreach
team members) drawn from the research team and interview panel,
individually graded each failure mode (1-5) in terms of the probabil-
ity, criticality and detectability via an online survey (Qualtrics XM,
Utah, USA (www.qualtrics.com)). The median grade for each param-
eter scored was used to calculate an overall clinical risk score for each
task step.
R.S. Bourne, D.L. Phipps, J.K. Jennings et al.
Fig. 1. Development process for the Hierarchical Task Analysis and Systematic Human Error Reduction and Prediction Approach, HTA: hierarchical task analysis;
NHS: National Health Service; SHERPA: systematic human error reduction and prediction approach
Results
Hierarchical Task Analysis (HTA)
Ten task steps were identified, comprising a total of 56 subordinate
task steps (Table 1 ). Task 5 was conditional; in that it was only required
if the ICU and hospital ward e-prescribing systems were not integrated.
In this case two subordinate tasks were required to transcribe the medi-
cation from one system to another and the need for clinical pharmacist
verification of the e- prescriptions.
Systematic Human Error Reduction and Prediction Approach (SHERPA)
Thirty-four of the 56 (61%) subordinate task steps were identified
to specifically involve medication continuity or safety aspects (Table 2
). The failure mode most commonly associated with each medication-
related task was A8 (Operation omitted). Indeed, when the other omit-
ted failure modes were included (C1 (Check omitted); I1 (Information
not communicated)), omitted failure modes accounted for twenty-four
of the 34 (71%) task steps. In terms of mitigation, most task steps (25/34
(74%)) had one or more recovery steps, that is, there was other oppor-
tunities to reduce errors within the overall plan.
The ICU healthcare professional panel completing the SHERPA anal-
ysis had a median (IQR) 6 years (3.5; 12) experience in their current
post.
In the SHERPA, Task 4 (Review and start/re-titrate appropriate
long-term medications) had the highest cumulative clinical risk score
(Table 3). The most common recovery mode code within Task 4 was
4.10 (Pharmacist performs a prescription “clinical check” or verifica-
tion (Operation omitted)).
3
Human Factors in Healthcare 2 (2022) 100030
The top 6 clinical risk scores for the failure modes involved 5 task
steps with some element of communication around medicines (3.6 [Rea-
son permanently discontinued medicines were stopped], 4.8 [Rationale
for antimicrobials], 4.9 [Medication follow-ups required], 5.1 [Tran-
scription of prescriptions and comments], 9.6 [Medications requiring
a “review” for re-titrating, re-initiating or weaning off]).
Discussion
Main findings
Our HTA and SHERPA analysis identified ten tasks and fifty-six sub-
ordinate tasks involved in the goal of safe continuity of medication for
ICU patients on transfer to a hospital ward. The number of subordinate
tasks, scope and number of ICU and ward-based healthcare profession-
als involved in the delivery of these tasks and primary failure modes
identified, highlight the complexity and vulnerability of this medication
system process. The SHERPA analysis illuminated the highest-risk task
steps to address and the inherent recovery modes that are already built
into the plan. The most frequently identified failure modes were based
on omission of an action (operation, check or information transfer).
The HTA tasks identified involve a minimum of three ICU health-
care professional groups and their respective hospital ward colleagues,
likely involving multiple personnel within each group, requiring effec-
tive collaboration and communication (Donchin et al., 2003). The im-
portance of strengthening communication around medication-related
information is highlighted by five of the top six clinical risk scores hav-
ing elements of communication failure within their remit. We have pre-
viously identified that interventions to improve information transfer are
one of the most investigated in medication safety for ICU patient trans-
 R.S. Bourne, D.L. Phipps, J.K. Jennings et al.
Table 1
Hierarchical task analysis for goal of safe continuity of medication for ICU patients on transfer to a hospital ward

Goal: Safe continuity of medication for ICU patients on transfer to a hospital ward
Task Step 1 2 3 4 5 6 7 8 9 10

Description Assess patient to Carry out Review and stop Review and Transcribe Prepare Medical team Transfer patient Nurse handover Pharmacist
decide if they are transfer any ICU specific start/re-titrate prescriptions and medications for handover handover
fit for transfer procedure checks medications appropriate comments on transfer
long-term new ward
medications prescribing
system
Process Do 1.1 to 1.9 in Do 2.1 then 2.2. Do 3.1 to 3.7 in Do 4.1 to 4.9 in If transcription of Do 6.1 to 6.4 in Do 7.1 to 7.5 in Do 8.1 to 8.7 in Do 9.1 to 9.7 in Do 10.1 to 10.2
plan order If a pharmacist order order. If a prescription to a order order order. 8.3-8.5 order for high-risk
available, then pharmacist different only required if patients or
2.3 available, then prescribing ICU and hospital medications
4.10 system is needed, ward systems not
do 5.1. If integrated
pharmacy staff
4

available then
5.2. If
transcription is
not required,
then go to Task 6
1.1 Review level 2.1 Ensure all 3.1 Review ICU 4.1 Update 5.1 Transcribe 6.1 Ensure any 7.1 Contact the 8.1 Confirm 9.1 Use ICU 10.1 ICU
Subordinate of care required medications prescriptions prescription with prescriptions and paper charts of ward medical patient ready for e-prescribing pharmacist hands
task steps administered any additional comments onto fluids/infusions team transfer system or over high-risk
have been medicines new ward system required are transfer report to patient to ward
recorded on ICU required (e.g. completed handover which pharmacy team
prescribing restarted medications have using ward
system(s) long-term been recently e-handover
medication) given, omitted or form/ email or
nearly due to telephone call
hospital ward

Human Factors in Healthcare 2 (2022) 100030

nurse
(continued on next page)
 R.S. Bourne, D.L. Phipps, J.K. Jennings et al.
Table 1 (continued)

Goal: Safe continuity of medication for ICU patients on transfer to a hospital ward
Task Step 1 2 3 4 5 6 7 8 9 10

1.2 Perform 2.2 Ensure all 3.2 Review 4.2 Prescribe 5.2 Pharmacy 6.2 Collect 7.2 Handover 8.2 Ensure ICU 9.2 Hand over 10.2 Hospital
physical nursing tasks pre-admission medication that staff conduct a medicines owned patient to transfer report any paper drug clinical
assessment complete on ICU medica- requires prescription by the patient/ hospital ward (with medication charts (if pharmacist
e-prescribing tions/medicines re-titration or transcription patient specific medical team sections) is applicable) acknowledges
system reconciliation re-initiation on check medication, using SBAR tool. completed medication plan
ward including Include any immediately and action
medicines in the relevant prior to transfer
fridge and CD medication issues
cabinet, ready for for follow up
transfer to new
5

ward
1.3 Assess vital 2.3 Ensure 3.3 Review 4.3 “Suspend” 6.3 Identify 7.3 Hospital 8.3 Print/ upload 9.3 Complete
signs medicines patient any medication continued ICU ward medical ICU medication bedside check of
reconciliation co-morbidities just prescribed medications team transfer report IV running
complete in ICU that is not yet (hospital ward acknowledges medications
e-prescribing clinically unlikely to have medication plan
system appropriate stock of) and action
1.4 Assess lab 3.4 Stop any ICU 4.4 Put a 6.4 Obtain up to 7.4 Refer to 8.4 Place transfer 9.4 Explain
results specific “review” in place 12 hours’ worth specialist team report into medications
medications no for suspended, of non-ward e.g. Outreach or patient medical supplied with
longer indicated re- stocked Diabetes Team (if notes patient to
titrated/initiated medication applicable) hospital ward
medication nurse
(continued on next page)

Human Factors in Healthcare 2 (2022) 100030

 R.S. Bourne, D.L. Phipps, J.K. Jennings et al.
Table 1 (continued)

Goal: Safe continuity of medication for ICU patients on transfer to a hospital ward
Task Step 1 2 3 4 5 6 7 8 9 10

1.5 Assess 3.5 Prescribe 4.5 Add rationale 7.5 Specialist 8.5 If medication 9.5 Identify with
medical history weaning regime for changes to team changes prior to hospital ward
for medication medications (if acknowledges transfer, nurse any
requiring not already referral for re-print/upload medications
weaning off documented) follow up an updated needing supply
transfer report from pharmacy
1.6 Decide 3.6 Document 4.6 Adjust doses 8.6 Book porter 9.6 Explain
whether patient medications that according to which
fit for transfer are permanently ward practice (if medications have
discontinued applicable) a “review” for
with rationale for re-titrating,
why they have re-initiating or
been stopped weaning off
1.7 Deem patient 3.7 Document 4.7 Adjust routes 8.7 Transfer 9.7 Hospital
fit for transfer to indications and according to patient to ward nurse
a ward plans for any ward practice (if hospital ward acknowledges
acute medicines applicable) with medication medication plan
commenced in and any and action
ICU with ongoing appropriate
6

indications additional
requiring further prescription
review after ICU charts
transfer
1.8 Inform 4.8 State
patient/ family rationale for
plan for transfer antimicrobials
to a ward (and codes for
restricted
antibiotics if
applicable)
1.9 Contact ward 4.9 State any
regarding bed medication
space and follow-ups
confirm required in the
approximate medication plan

Human Factors in Healthcare 2 (2022) 100030

time of bed
availability
4.10 Pharmacist
performs a
prescription
“clinical check”
or verification
R.S. Bourne, D.L. Phipps, J.K. Jennings et al.
Table 2
Medication-related task steps SHERPA
Task
Step Failure Mode Description
2.1 A9 (Operation incomplete) Not all medication
administered is recorded on
the patient e-prescribing
record
2.3 A8 (Operation omitted) Best possible medication
history not completed by
medicines reconciliation and
entered on ICU e-prescribing
system prior to patient
transfer
3.4 A8 (Operation omitted) Medication intended for
short-term or ICU only
indication e.g., stress
ulceration not stopped
3.5 A8 (Operation omitted) Medication requiring
weaning regimen may not be
weaned corrected
3.6 A8 (Operation omitted) Medication with ongoing
indication but requiring a
review according to clinical
progress or status not
identified
3.7 A8 (Operation omitted) Medication permanently
discontinued and rationale
not documented
4.1 A8 (Operation omitted) Medication that could be
re-started prior to transfer
remains omitted
4.2 A8 (Operation omitted) Medication that could be
re-titrated prior to transfer
remains omitted
4.3 A9 (Operation incomplete) Medication that is not
clinically appropriate to be
restart yet, has an active
prescription for nurse
administration
4.4 A9 (Operation incomplete) There is an indefinite
suspension of prescribed
medication without a date
prompt for review
4.5 A8 (Operation omitted) Indication of the medication
may be unclear
4.6 A8 (Operation omitted) ICU dose of a specific
medicine continues into ward
use without the associated
monitoring
Consequence
Patient at risk of duplicate
dose on transfer to the ward
Delay in medicines
reconciliation which can in
turn delay ability to do
structured medication review
and increasing medication
error risks for the patient
Increased polypharmacy
burden for the patient
potentially long-term
increasing the risk of adverse
drug events
Risk of patient withdrawal
symptoms (adverse drug
event) if stopped abruptly or
potential for inappropriate
long-term continuation and
increased polypharmacy
burden (again increased
adverse drug event risk for
patient)
Opportunity for medication
review decreased and
increased polypharmacy
burden for the patient
potentially long-term
increasing the risk of adverse
drug events
Risk of inappropriate
restarting of the medication
at a later date with patient
re-exposure to adverse event
Potentially important
long-term medication is
delayed restarting, or not
restarted and may lead to an
adverse drug event
Potentially important
long-term medication is
delayed restarting and may
lead to an adverse drug
event, or medication is
started at original dose and
the patient experiences and
augmented response adverse
drug event
The medicine is
administered, and the patient
is vulnerable to experience
an adverse drug event
Potentially important
long-term medication is
delayed restarting and may
lead to an adverse drug event
Making medication review
more protracted so that the
review may be delayed or
may not happen
Augmented effect of the
medicine with increased risk
of adverse drug events
without the ICU monitoring
7
Human Factors in Healthcare 2 (2022) 100030
Recovery Remedial measures
9.1 Include all medication administration
check as part of transfer checklist for
nursing staff
Incomplete medication history
documentation creates a flag for hospital
ward clinical pharmacy team to prioritise
to complete
3.1-3.3 Include rationale for all acute medicines
when prescribed
4.10, 10.1 Include rationale for all acute medicines
when prescribed and document need for
weaning regimen rather than abrupt
stopping.
Inform patient and family when
appropriate
10.1 Include rationale for all acute medicines
when prescribed. Inform patient and
family when appropriate.
4.10, 10.1 Include documentation and rationale for
all medication permanently discontinued.
Inform patient and family when
appropriate
10.1 Encourage prescribing of all medication in
ICU and then suspending medication not
currently indicated. Include medication
review and prompt to restart clinically
appropriate long-term medication check
in medication transfer checklist
4.10 Include medication review and prompt to
restart clinically appropriate long-term
medication check in medication transfer
checklist supported by education and
training on medicines and scenarios that
need re-titration of medicines
4.10 The e-prescribing system functionality
allows medication to be suspended within
same menu as prescribing
The e-prescribing system prompts entry of
a review period on all prescribed
medicines suspended. Medication review
undertaken on the ward shortly after
patient transfer (within 48 hours)
4.10, 10.1 Education and training for medicine
rationale/ indication to be added at time
of prescribing to aid review
4.10, 10.1 Education and training for medicine
rationale/ indication to be added at time
of prescribing to aid review. Medication
review undertaken on the ward shortly
after patient transfer (within 48 hours)
(continued on next page)
R.S. Bourne, D.L. Phipps, J.K. Jennings et al.
Table 2 (continued)
Failure Mode Description
Task
Step
4.7 A9 (Operation incomplete) Some routes of medicines
continued on the hospital
ward are not optimised for
ward team administration
4.8 I1 (Information not communicated) Microbiology code for
restricted antibiotic not
provided on transfer
4.9 A8 (Operation omitted) Medication plan does not
contain relevant follow up
direct for the hospital ward
team
A8 (Operation omitted) Prescription chart medicines
4.10 not clinically checked/
verified by a clinical
pharmacist prior to ICU
transfer
5.1 I1 (Information not communicated) Prescription rationale and
supporting information not
included on prescriptions in
hospital ward e-prescribing
system
5.2 A8 (Operation omitted) Prescription chart medicines
on hospital ward
e-prescribing system not
clinically checked/ verified
by a clinical pharmacist prior
to ICU transfer
6.1 A8 (Operation omitted) Additional paper chart that
may be required is not
completed
6.2 A9 (Operation incomplete) Not all medication available
for transfer with the patient
6.4 A9 (Operation incomplete) Not all medication required
transferred with the patient
7.3 I1 (Information not communicated) Action plan not confirmed
7.5 I1 (Information not communicated) Action plan not confirmed
8.1 C1 (Check omitted) No check that patient is
ready for transfer
8.2 A9 (Operation incomplete) Not all pertinent medication
information included in the
transfer report
8.5 A8 (Operation omitted) Paper copy of transfer report
is not accurate
9.1 I3 (Information communication Not all pertinent medication
incomplete) information communicated
to the hospital ward nurse
9.2 A8 (Operation omitted) Not all paper prescription
charts are handed over to the
hospital ward nurse
Consequence
Potential for delay in dose
administration, need for
re-prescribing or increased
risk of administration error
Delay in antimicrobial
administration of restricted
antibiotic
Delay to targeted medication
review of important
medication issues
Increase in prescription
medication errors with
potential for patient adverse
events
Delay to targeted medication
review of important
medication issues
Increased in prescription
transcription medication
errors with potential for
patient adverse events
Missing prescription
information that may mean a
delay in medication
administration or missed
doses
Delayed or missed doses of
medicines on the hospital
ward
Delayed or missed doses of
medicines on the hospital
ward
Follow up and action may be
delayed or omitted
Specialist team follow up and
action may be delayed or
omitted
Patient transfer proceeds
without confirming the
patient is ready for transfer
Hospital ward staff time
required to retrieve
information independently
from ICU patient episode.
Delay medication review of
follow up
Transfer report may contain
inaccurate medication
information
Delay in medication
administered, dose omitted
or double dose given
Delay in medication
administered, dose omitted
or double dose given.
Re-prescribing of paper chart
may be needed
8
Human Factors in Healthcare 2 (2022) 100030
Recovery Remedial measures
4.10, 9.1 Include medication route review prompt
in medication transfer checklist.
Medication review undertaken on the
ward shortly after patient transfer (within
48 hours)
4.10, Microbiology codes added to
6.3-6.4, 9.1, antimicrobial medicines when prescribed.
9.4-9.5, Exemption of ICU transfer patients from
10.1 restricted antimicrobial policy
10.1 Medication review undertaken on the
ward shortly after patient transfer (within
48 hours)
10.1 Medication review undertaken on the
ward shortly after patient transfer (within
48 hours)
4.5, 4.9, Integrated e-prescribing system across
4.10, 10.1 ICU and hospital wards. Medication
review undertaken on the ward shortly
after patient transfer (within 48 hours)
10.1 Integrated e-prescribing system across
ICU and hospital wards. Medication
review undertaken on the ward shortly
after patient transfer (within 48 hours)
8.7, 9.2 Integrated e-prescribing system across
ICU and hospital wards that has
functionality for all prescription types
used in the hospital
8.7, 9.4 Each patient has a designated location for
storing all their medicines together, when
possible, with a flag for any CDs or fridge
medicines
9.4-9.5 Prompt on nurse transfer checklist for
transfer to include required medication
supply
8.2-8.4 Automatic documentation of handover
action plan in hospital ward team task list
Automatic documentation of handover
action plan in specialist team task list
Transfer checklist completed prior to
transfer of patient
7.2-7.3, 9.6, Automatic pre-population of relevant
10.1 medication fields in transfer report
9.1, 9.6 Transfer report accessible electronically in
hospital ward e-prescribing or patient
record system
Integrated e-prescribing system across
ICU and hospital wards that has
functionality for all prescription types
used in the hospital
Integrated e-prescribing system across
ICU and hospital wards that has
functionality for all prescription types
used in the hospital
(continued on next page)
R.S. Bourne, D.L. Phipps, J.K. Jennings et al. Human Factors in Healthcare 2 (2022) 100030

Table 2 (continued)

Failure Mode Description Consequence Recovery Remedial measures

Task
Step

9.3 C1 (Check omitted) Check of IV infusions not
completed
9.4 I1 (Information not communicated) Information not provided on
medication supplied with
patient
9.5 C1 (Check omitted) Check of medications
requiring supply from
pharmacy not completed
9.6 I1 (Information not communicated) Information on medication
requiring weaning,
re-titration or re-initiating
not provided
9.7 I3 (Information communication Hospital ward nurses does
incomplete) not acknowledge all
information provided
A9 (Operation incomplete) Clinical pharmacist does not
10.2 acknowledge handover
receipt and medication
review delayed (>48 hours)
or not undertaken
Increased risk of medication
administration error
Lack of understanding about
medication supplied with
patient and action resulting
in duplication of effort or
information retrieval
Delay in medication dose
administration or missed
dose
Delay in medication review
and increased adverse drug
event risk
Not all medication
information acknowledged
and then available for action.
Suboptimal communication
of the medication plan and
related action(s)
Increased risk of medication
error unresolved with
adverse drug event risk
Hospital bedside safety check completed
by hospital ward nurses
Ward nurse completes own assessment of
medications needed vs medications
supplied
Hospital ward nurses checks availability
of all medicines required for patients
during their shift on e-prescribing system
8.2 Hospital ward nurses also reads
medication transfer report
10.1-2 Nurse handover structure includes a
check of information and understanding
7.2-7.3, If electronic handover, flag to prompt
8.2-8.4 identification and acknowledgement of
communication. Sufficient clinical
pharmacy staff to undertake the required
patient services

Table 3
Task steps failure mode by clinical risk score

Failure mode Clinical Risk Score

4.7 Adjust routes according to ward practice (if applicable) (Operation incomplete) 45
9.6 Explain which medications have a “review” for re-titrating, re-initiating or weaning off (Information not communicated) 45
4.9 State any medication follow-ups required in the medication plan (Operation omitted) 40.5
4.8 State rationale for antimicrobials (and codes for restricted antibiotics if applicable) (Information not communicated) 39
3.6 Document medications that are permanently discontinued with rationale for why they have been stopped (Operation 36
omitted)
5.1 Transcribe prescriptions and comments onto new ward system (Information not communicated) 36
4.4 Put a “review” in place for suspended, re-titrated/initiated medication (Operation incomplete) 31.5
3.7 Document indications and plans for any acute medicines commenced in ICU with ongoing indications requiring further 30
review after ICU transfer (Operation omitted)
4.1 Update prescription with any additional medicines required (e.g. restarted long-term medication) (Operation omitted) 30
4.3 “Suspend” any medication just prescribed that is not yet clinically appropriate (Operation incomplete) 30
6.1 Ensure any paper charts of fluids/infusions required are completed (Operation omitted) 28
3.5 Prescribe weaning regime for medication requiring weaning off (Operation omitted) 27
9.3 Complete bedside check of IV running medications (Check omitted) 27
8.5 If medication changes prior to transfer, re-print/upload an updated transfer report (Operation omitted) 26.25
3.4 Stop any ICU specific medications no longer indicated (Operation omitted) 24
4.5 Add rationale for changes to medications (if not already documented) (Operation omitted) 24
5.2 Pharmacy staff conduct a prescription transcription check (Operation omitted) 24
6.2 Collect medicines owned by the patient/ patient specific medication, including medicines in the fridge and CD cabinet, 24
ready for transfer to new ward (Operation incomplete)
7.5 Specialist team acknowledges referral for follow up (Information not communicated) 24
9.4 Explain medications supplied with patient to hospital ward nurse (Information not communicated) 24
9.5 Identify with hospital ward nurse any medications needing supply from pharmacy (Check omitted) 24
9.7 Hospital ward nurse acknowledges medication plan and action (Information communication incomplete) 24
10.2 Hospital clinical pharmacist acknowledges medication plan and action (Operation incomplete) 22.5
4.6 Adjust doses according to ward practice (if applicable) (Operation omitted) 21
6.4 Obtain up to 12 hours’ worth of non-ward stocked medication (Operation incomplete) 20
8.2 Ensure ICU transfer report (with medication sections) is completed immediately prior to transfer (Operation incomplete) 20
4.2 Prescribe medication that requires re-titration or re-initiation on ward (Operation omitted) 18.75
4.10 Pharmacist performs a prescription “clinical check” or verification (Operation omitted) 18
9.1 Use ICU e-prescribing system or transfer report to handover which medications have been recently given, omitted or nearly 18
due to hospital ward nurse (Information communication incomplete)
9.2 Hand over any paper drug charts (if applicable) (Operation omitted) 18
7.3 Hospital ward medical team acknowledges medication plan and action (Information not communicated) 16
2.1 Ensure all medications administered have been recorded on ICU prescribing system(s) (Operation incomplete) 15
2.3 Ensure medicines reconciliation complete in ICU e-prescribing system (Operation omitted) 15
8.1 Confirm patient ready for transfer (Check omitted) 15

9
R.S. Bourne, D.L. Phipps, J.K. Jennings et al.
fers (Bourne, Jennings, Panagioti, et al., 2022). The importance of for-
mal structured handovers by medical and nursing staff when a critical
care patient transfers to a hospital ward is recognised, including the
need to include a medication plan (National Institute for Health and
Care Excellence (2007).; Joel Meyer, Andrew Slack, Carl Waldmann,
Anthony Bastin, Melanie Gager, Joanne McPeake, Tara Quasim, 2021;
Rhodes et al., 2012). We also identified the importance of clinical phar-
macist handovers in our HTA, but that omission of information or oper-
ation incomplete was the most likely failure mode.
Exploration with wider literature
Mol et al, (van Mol et al., 2017) used intervention mapping to de-
velop a person-centred discharge protocol in the ICU setting. However,
they did not specifically explore the medication continuity or safety as-
pects of this patient and family care transition. Nevertheless, they did
highlight the complexity of high-quality patient transfer and that a sim-
ple universal strategy would be unlikely to address the many individual
and care challenges. Recently, we have developed this understanding
by identifying the priorities for medication-related intervention compo-
nents to improve medication safety for intensive care patients transfer-
ring to a hospital ward (Bourne, Jennings, & Ashcroft, 2022).
The challenges and considerations around implementing interven-
tions to improve medication safety for ICU patients transferring to a
hospital ward have recently been explored (Mccarthy et al., 2022). Im-
plementation requires appropriate acknowledgement of local context,
resources and stakeholder involvement (healthcare professionals and
patient and family) (Mccarthy et al., 2022). Moreover, the underpin-
ning evidence base of the intervention is critical, as are the stakeholder
beliefs about consequences if the safety elements are to be fully en-
gaged with. An example of such a challenge is the onus put on phar-
macist clinical check in the recovery mode provision for the highest risk
task (4 - medication review). (NHS England, 2022) Although clinical
pharmacists are widely available in UK critical care units, in line with
NHS England’s service specification for critical care staffing in hospitals
(NHS England, 2022), geographical variations in UK staffing levels, 7
day services(Borthwick et al., 2018) and scope of practice exist, includ-
ing the ability to undertake medication reconciliation on ICU patient
transfer to a hospital ward (Bourne et al., 2018). As many patients are
transferred outside the hours clinical pharmacy services are routinely
available, this limits the effectiveness of pharmacist-dependent recov-
ery modes. From a human factors perspective, a fundamental concern
with pharmacist checking as a single safety barrier is that relies on the
ability of pharmacists to detect and resolve discrepancies in the face of
performance-shaping factors such as time pressure, interruptions and
disorganised work environments (e.g. Sujan et al., 2011).
Task four (medication review) also had the highest cumulative risk
score. We have previously identified that multi-component interven-
tions based on education of staff and guidelines were effective at re-
ducing inappropriate continuation of ICU-only medication by hospital
discharge (Bourne, Jennings, Panagioti, et al., 2022). However, we ac-
knowledged that the appropriate recommencement of clinically impor-
tant chronic medication was a much more complex process and would
require effective co-ordination across clinical areas and multiprofes-
sional teams including medicines reconciliation, and medication review
(Bourne, Jennings, Panagioti, et al., 2022). Our SHERPA results under-
line this by identifying the clinical vulnerability of this task within the
plan for delivering safe continuity of medication for ICU patients on
transfer to a hospital ward.
Task five (transcription) was conditional and only required to ad-
dress the increased risk of when ICUs and hospital wards used differ-
ent e-prescribing systems necessitating an additional transcription step.
This additional step could increase the risk of prescribing errors and
loss of information (e.g. prescription annotation, loss of accessibility to
notes). In a two-centre study with unintegrated e-prescribing, Bosma
et al,(Bosma et al., 2018) reported that pharmacist-led medicines rec-
10
Human Factors in Healthcare 2 (2022) 100030
onciliation on ICU patient transfer to a hospital ward reduced medica-
tion errors four-fold and potential patient harm. Tully et al,(Tully et al.,
2019) reported that in a multicentre, retrospective, point prevalence
study, that medication transcription was associated with an almost 3-
fold lower odds ratio in medication errors at ICU transfer. This is pre-
sumably by enforcing a medicines reconciliation and medication re-
view opportunity to discontinue medication without an ongoing indi-
cation (Task Step 3). Nevertheless, the additional transcription phase
creates an opportunity for error unless mitigated by a recovery step
such as clinical pharmacist verification. In a single centre study, Dabliz
et al,(Dabliz et al., 2021) reported that the introduction of an integrated
e-prescribing system (ICU and hospital), reduced medication errors dur-
ing ICU transfers.
Strengths and Limitations
A notable strength of our results is that we included healthcare pro-
fessionals and incorporated insights from four NHS centres with differ-
ent configurations and e-prescribing systems. Another strength was the
triangulation of data from various sources (documentary analysis, inter-
views, and practitioner panel validation). These undertakings make our
results more generalisable and hence transferable to the wider critical
care community. Our research team included a human factors specialist
(DLP), who facilitated team meetings and application of the HTA and
SHERPA techniques by the healthcare professionals, ensuring technical
and subject expertise was provided. This combined approach strength-
ens our research findings.
We appreciate that a group meeting, promoting discussion and con-
sensus is an alternative method to individual healthcare professional
grading of the clinical risk scores, which may have led to different
results (Ashley & Armitage, 2010; Franklin et al., 2012; Jeon et al.,
2007; Shebl et al., 2009). However, within the constraints of the unique
clinical demands within ICU and social distancing requirements dur-
ing COVID-19 pandemic, we felt that this was the best way to achieve
full multiprofessional input. We also acknowledge the rater subjectiv-
ity inherent in the SHERPA scoring, (Franklin et al., 2012) although
by having a panel of ten healthcare professionals will have reduced this
effect. There are potentially inter-professional variation in severity scor-
ing of failures and medication errors,(Bourne et al., 2016; Williams &
Ashcroft, 2009) which we again reduced by combing multiprofessional
views. Finally, we acknowledge that the risk score results and prioriti-
sation are sensitive to the numerical sum of the individual criticality,
probability and detectability scores (Franklin et al., 2012).
For each subordinate task step there were the potential for several
failure modes. However, we chose to focus on the primary or most likely
failure mode for each task step given the considerable number of task
steps involved. We feel it is unlikely that additional failure modes would
have changed the results and findings notably.
Research and practice recommendations
These HTA and SHERPA results provide further guidance on the re-
search and practice initiatives required to improve medication safety
for ICU patients transferring to the hospital ward. Firstly, the complex-
ity around medication safety systems is clear. Intervention development
needs to acknowledge the importance of medication review and effec-
tive multiprofessional communication of medication-related informa-
tion across the interface in care. Recovery systems in place need to be
reliably delivered for all patients. Finally, the intervention will need
to be appropriately evaluated, as any implementation of interventions
must be based on a solid evidence base to be adopted in routine practice.
Conclusions
The safe continuity of medication for ICU patients on transfer to a
hospital ward is complex, involving many tasks and healthcare staff, and
R.S. Bourne, D.L. Phipps, J.K. Jennings et al.
presenting several error-producing conditions. In response, the primary
failure modes, criticality and recovery steps provide direction on the
task steps to focus system interventions on. Medication review on ICU
prior to patient transfer and communication around medication changes
and plans, are particularly important risks that require addressing in any
intervention developed to improve medication safety in this patient care
transition.
Implications and Applications
We have identified that medication review and staff communication
of medication plans are priority areas to address to improve medication
safety for intensive care patients transferring to a hospital ward.
Impact Statement
Failures in medication review and staff communication around
medicines, present important risks to medication safety for intensive
care patients transferring to a hospital ward and present a priority to
address.
Data availability statement
The datasets used and/or analysed during the current study are avail-
able from the corresponding author on reasonable request.
Ethics Approval
Ethical (The University of Manchester, Ref: 2020-10852-17342) and
NHS Health Research Authority (HRA) (IRAS 292456) approval was
granted for the study.
Declaration of Competing Interest
The authors declare the following financial interests/personal rela-
tionships which may be considered as potential competing interests:
Dr Richard S Bourne reports financial support and article publishing
charges were provided by National Institute for Health and Care Excel-
lence. Prof Darren M Ashcroft reports financial support was provided by
National Institute for Health and Care Excellence
Funding
This report is independent research supported by the National Insti-
tute for Health and Care Research, HEE/NIHR ICA Programme Clinical
Lectureship, Dr Richard Bourne, NIHR300444. DMA is funded by the
National Institute for Health and Care Research Greater Manchester Pa-
tient Safety and Translational Research Centre (PSTRC-2016-003). The
views expressed in this publication are those of the author(s) and not
necessarily those of the NHS, the National Institute for Health and Care
Research or the Department of Health and Social Care.
Acknowledgements
The authors would like to thank all the participants for taking the
time to provide their insightful views that enriched the findings of this
research.
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