ArticleArchives of disease in childhood2019
Exploring the human factors of prescribing errors in paediatric intensive care units.
Article in Archives of disease in childhood, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 14 papers, 5 of them syntheses that pooled it.
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Who cites it
14 citing papers in PubMed, 5 syntheses or guidelines pooled it.
- Interventions to Reduce Pediatric Prescribing Errors in Professional Healthcare Settings: A Systematic Review of the Last Decade.Paediatric drugs · 2021Pooled it
- The impact of health information technology on prescribing errors in hospitals: a systematic review and behaviour change technique analysis.Systematic reviews · 2020Pooled it
- Preventable medication harm across health care settings: a systematic review and meta-analysis.BMC medicine · 2020Pooled it
- Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review.BMC pediatrics · 2019Pooled it
- Prevalence and Nature of Medication Errors and Preventable Adverse Drug Events in Paediatric and Neonatal Intensive Care Settings: A Systematic Review.Drug safety · 2019Pooled it
- Impact of a clinical decision support system on paediatric drug dose prescribing: a randomised within-subject simulation trial.BMJ paediatrics open · 2023Trial
- Article
- Rural nurses' antiretroviral prescribing practices in children, Limpopo province, South Africa.Southern African journal of HIV medicine · 2023Article
- c4c: Paediatric pharmacovigilance: Methodological considerations in research and development of medicines for children - A c4c expert group white paper.British journal of clinical pharmacology · 2022Review
- Human factors and ergonomics methods for pharmacy research and clinical practice.Research in social & administrative pharmacy : RSAP · 2021Review
- Usability and Effectiveness of Immersive Virtual Grocery Shopping for Assessing Cognitive Fatigue in Healthy Controls: Protocol for a Randomized Controlled Trial.JMIR research protocols · 2021Article
- A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children's Intensive Care.Paediatric drugs · 2021Article
- Hospital pharmacists' experiences of participating in a partnered pharmacist medication charting credentialing program: a qualitative study.BMC health services research · 2021Article
- Medication Error During the Day and Night Shift on Weekdays and Weekends: A Single Teaching Hospital Experience in Riyadh, Saudi Arabia.Risk management and healthcare policy · 2021Article
Corrections and comments
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Authors and funding
3 authors.
Funding
Abstract
objectiveTo explore the factors contributing to prescribing error in paediatric intensive care units (PICUs) using a human factors approach based on Reason's theory of error causation to support planning of interventions to mitigate slips and lapses, rules-based mistakes and knowledge-based mistakes.
methodsA hierarchical task analysis (HTA) of prescribing was conducted using documentary analysis. Eleven semistructured interviews with prescribers were conducted using vignettes and were analysed using template analysis. Contributory factors were identified through the interviews and were related to tasks in the HTA by an expert panel involving a PICU clinician, nurse and pharmacist.
resultsPrescribing in PICU is composed of 30 subtasks. Our findings indicate that cognitive burden was the main contributory factor of prescribing error. This manifested in two ways: physical, associated with fatigue, distraction and interruption, and poor information transfer; and psychological, related to inexperience, changing workload and insufficient decision support information. Physical burden was associated with errors of omission or selection; psychological burden was linked to errors related to a lack of knowledge and/or awareness. Social control through nursing staff was the only identified control step. This control was dysfunctional at times as nurses were part of an informal mechanism to support decision making, was ineffective.
conclusionsCognitive burden on prescribers is the principal latent factor contributing to prescribing error. This research suggests that interventions relating to skill mix, and communication and presentation of information may be effective at mitigating rule and knowledge-based mistakes. Mitigating fatigue and standardising procedures may minimise slips and lapses.
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