Evidence map›Paper›PMID 38557363›Full record

ArticleErgonomics2025

Understanding the informal aspects of medication processes to maintain patient safety in hospitals: a sociotechnical ethnographic study in paediatric units.

Adam B Sutherland, Denham L Phipps, Suzanne Grant, Joanne Hughes, Stephen Tomlin, Darren M Ashcroft

Open access · hybridAbstract read
In one paragraph

Article in Ergonomics, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it
0cells of the map it votes in
1citing papers in PubMed
2.2field-weighted citation impact, top 15% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

1 citing paper in PubMed, 3 citations in OpenAlex.

  1. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

6 authors at 5 institutions in 3 countries.

Adam B SutherlandMedicines Optimisation Research Group, School of Pharmacy & Medical Sciences, Faculty of Life Sciences, University of Bradford, Bradford, UK.ORCID 0000-0002-5198-3727
Denham L PhippsDivision of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK.
Suzanne GrantDivision of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK.
Joanne HughesMother's Instinct, Cambridge, UK.
Stephen TomlinChildren's Medicines Research & Innovation Centre, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
Darren M AshcroftDivision of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK.
Manchester Academic Health Science Centre · GBGreat Ormond Street Hospital for Children NHS Foundation Trust · GBMother Hospital · INUniversity of Bradford · GBUniversity of Dundee · GB

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

Adverse drug events (ADEs) are common in hospitals, affecting one in six child in-patients. Medication processes are complex systems. This study aimed to explore the work-as-done of medication safety in three English paediatric units using direct observation and semi-structured interviews. We found that a combination of the physical environment, traditional work systems and team norms were among the systemic barriers to medicines safety. The layout of wards discouraged teamworking and reinforced professional boundaries. Workspaces were inadequate, and interruptions were uncontrollable. A less experienced workforce undertook prescribing and verification while more experienced nurses undertook administration. Guidelines were inadequate, with actors muddling through together. Formal controls against ADEs included checking (of prescriptions and administration) and barcode administration systems, but these did not integrate into workflows. Families played an important part in the safe administration of medication and provision of information about their children but were isolated from other parts of the system.

Indexed as

Medication ErrorsMedication Systems, HospitalPatient SafetyAnthropology, CulturalChildDrug-Related Side Effects and Adverse ReactionsEnglandFemaleHospitals, PediatricHumansMaleQualitative Researchethnographyhuman factorsmedication safetyPaediatricssystems ergonomics

Identifiers

PMID38557363
PMCPMC11835306
OpenAlexW4393380964

What OpenQuestion holds

Textmetadata
LicenceCC BY
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.