Table 3

Themes and categories identified from the interviews

Individual factorsInexperience.
Lack of skills or knowledge.
Inexperienced in paediatric prescribing (eg, an adult anaesthetist on a short rotation).
Organisational factorsDivergent practice and systems.
Conflicting priorities.
Different protocols between patients receiving non-intensive care unit (ICU) care (postoperative recovery) and those receiving ICU care.
Task-related factorsAmbiguous or inaccessible information.
Reliance on memory and previous experience.
Problem recognition.
Task complexity.
Inability to locate guidelines and procedures on the intranet because of a lack of computer facilities.
Team-related factorsFlat hierarchy.
Leadership and support.
Verbal communication.
Lack of handover related to medicines that the patient is receiving on admission.
Work-related factorsDistraction and interruption.
Rewriting a complex medication chart and being asked to review blood gases, or answer the telephone.