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In knowledge‐based performance, a clinician is solving problems in a new and unfamiliar situation. Clinicians may try to figure out how to perform based on what they already know, using trial and error, or even guessing at the solution. This is very dangerous. For example, Cindy is an experienced nurse who has been working in critical care for 15 years. When she arrives on her shift, her patient is receiving Continuous Renal Replacement Therapy. Cindy has not previously managed this therapy and is not familiar with the supplies and fluids used. Rather than proceeding independently, Cindy needs to stop and consider requesting a safer assignment. Alternatively, Cindy may work with an expert and consult a written resource such as an evidence‐based protocol while providing care.

Nurses and nurse leaders need to understand skill, rule, and knowledge‐based performance when investigating errors. Nurses who have been involved in an error should focus on how they made the decision they did. Did they develop a short cut or work‐around to save time? Did they fail to do a double check of their own work? Did they proceed even though they were not familiar with the procedure? Each type of error requires a different solution. The three performance modes are critical to keep in mind when designing error prevention strategies.