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Exploring the human factors of prescribing errors in paediatric intensive care units
  1. Adam Sutherland1,2,3,
  2. Darren M Ashcroft1,3,
  3. Denham L Phipps1,3
  1. 1 Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
  2. 2 Paediatric Intensive Care Unit, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
  3. 3 NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Science Centre (MAHSC), Manchester, UK
  1. Correspondence to Adam Sutherland, Division of Pharmacy and Optometry, The University of Manchester, Manchester M13 9PL, UK; adam.sutherland{at}


Objective To 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.

Methods A 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.

Results Prescribing 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.

Conclusions Cognitive 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.

  • medication errors
  • prescribing errors
  • paediatric intensive care
  • human factors

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  • Contributors AS conceptualised and undertook study procedures under supervision of DMA and DLP. AS and DLP undertook data analysis. AS drafted the manuscript and both DMA and DLP have significantly contributed to all parts. All authors have had sight and agreement of the final manuscript.

  • Funding This study was funded through a National Institute for Health Research (NIHR)/Health Education England (HEE) Integrated Clinical Academic Training Programme MClinRes Studentship awarded to AS and supervised by DMA and DLP at the University of Manchester. This paper presents independent research funded by the NIHR and HEE.

  • Disclaimer The views expressed as those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Ethical approval was granted by the University of Manchester Research Ethics Committee (UREC 15582).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There are no additional data associated with this study other than that reported.

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