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

Study

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

April 17, 2024

Sutherland AB, Phipps DL, Grant S, et al. Ergonomics. 2024;Epub Apr 1.

View more articles from the same authors.

Medication errors are often the result of both individual failures and system flaws. This qualitative study found that medication safety practices in pediatric inpatient units are often hindered by issues in the physical environment (e.g., workspace layouts, interruptions) and by poorly integrated workflows.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Medication safety gaps in English pediatric inpatient units: an exploration using work domain analysis.

March 6, 2024

Exploring the human factors of prescribing errors in paediatric intensive care units.

March 27, 2019

Preventable medication harm across health care settings: a systematic review and meta-analysis.

February 17, 2021

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.

July 31, 2019

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

June 7, 2023

Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies.

February 6, 2019

An investigation of occupational subgroups with respect to patient safety culture.

March 14, 2012

Understanding procedural violations using Safety-I and Safety-II: the case of community pharmacies.

August 22, 2018

Developing a learning health system: insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care.

November 14, 2018

Exploring safety systems for dispensing in community pharmacies: focusing on how staff relate to organizational components.

September 17, 2014

Examining the attitudes of hospital pharmacists to reporting medication safety incidents using the theory of planned behaviour.

September 9, 2015

Capturing patients' perspectives on medication safety: the development of a patient-centered medication safety framework.

May 8, 2019

Medication safety in community pharmacy: a qualitative study of the sociotechnical context.

December 2, 2009

Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study.

January 16, 2013

Psychosocial influences on safety climate: evidence from community pharmacies.

December 14, 2011

Pharmacist work stress and learning from quality related events.

November 9, 2016

Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: a systematic review.

December 11, 2019

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

December 16, 2020

Prevalence, nature, severity and preventability of adverse drug events in mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) study.

August 11, 2021

Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care- a modified e-Delphi study.

January 17, 2024

Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study.

October 21, 2020

Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study.

November 13, 2019

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

January 11, 2023

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

Assessment of patient medication adherence, medical record accuracy, and medication blood concentrations for prescription and over-the-counter medications.

November 28, 2018

For children admitted to hospital, what interventions improve medication safety on ward rounds?

March 1, 2023

unDerstandIng the cauSes of mediCation errOrs and adVerse drug evEnts for patients with mental illness in community caRe (DISCOVER): a qualitative study.

February 28, 2024

Identifying violation-provoking conditions in a healthcare setting.

December 17, 2008

Personal formularies of primary care physicians across 4 health care systems.

August 4, 2021

Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals.

August 26, 2015

Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study.

June 12, 2019

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial.

March 1, 2023

Surgical specimen management: a descriptive study of 648 adverse events and near misses.

October 5, 2016

February 2, 2022

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD).

September 15, 2021

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

A multi-method exploratory evaluation of a service designed to improve medication safety for patients with monitored dosage systems following hospital discharge.

October 25, 2023

Learning from the design, development and implementation of the Medication Safety Thermometer.

February 8, 2017

What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff.

January 23, 2019

Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study.

April 1, 2015

Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink.

November 25, 2015

Exploring the causes of junior doctors' prescribing mistakes: a qualitative study.

October 22, 2014

Primary care medication safety surveillance with integrated primary and secondary care electronic health records: a cross-sectional study.

July 22, 2015

Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review.

June 25, 2014

Medication errors: how reliable are the severity ratings reported to the National Reporting and Learning System?

September 23, 2009

Prevalence of adverse drug events in ambulatory care: a systematic review.

July 27, 2011

Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence.

March 27, 2013

Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence.

September 18, 2013

Risk factors for hospital admissions associated with adverse drug events.

August 28, 2013

Patient safety in healthcare preregistration educational curricula: multiple case study-based investigations of eight medicine, nursing, pharmacy and physiotherapy university courses.

June 19, 2013

Hospital admissions associated with medication non-adherence: a systematic review of prospective observational studies.

May 23, 2018

Frequency and nature of medication errors and adverse drug events in mental health hospitals: a systematic review.

September 13, 2017

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: a multi-centre study.

March 11, 2020

Retrospective analysis of medication incidents reported using an on-line reporting system.

December 13, 2006

Sources and magnitude of error in preparing morphine infusions for nurse–patient controlled analgesia in a UK paediatric hospital.

November 30, 2016

Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists.

July 25, 2018

Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals.

April 2, 2008

'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events.

January 25, 2012

PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations.

July 31, 2019

It's not all about me: motivating hand hygiene among health care professionals by focusing on patients.

February 15, 2012

Developing strategic recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication safety.

November 16, 2022

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

Changes in medical errors after implementation of a handoff program.

November 12, 2014

Prospective study of the multisite spread of a medication safety intervention: factors common to hospitals with improved outcomes.

February 7, 2024

Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington.

June 10, 2020

Physicians' perspectives regarding prescription drug monitoring program use within the Department of Veterans Affairs: a multi-state qualitative study.

April 18, 2018

The role of housestaff in implementing medication reconciliation on admission at an academic medical center.

June 16, 2010

Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion.

December 2, 2020

Saving lives: a meta-analysis of team training in healthcare.

August 3, 2016

Humanizing harm: using a restorative approach to heal and learn from adverse events.

May 4, 2022

Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors.

February 9, 2011

Cultural and associated enablers of, and barriers to, adverse incident reporting.

June 23, 2010

Frequency of inappropriate medical exceptions to quality measures.

March 31, 2010

Improving handoffs in the emergency department.

October 28, 2009

Between demarcation and discretion: the medical-administrative boundary as a locus of safety in high-volume organisational routines.

August 1, 2018

Dynamics of dignity and safety: a discussion.

January 24, 2018

The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice.

June 14, 2017

Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care.

December 13, 2017

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial.

August 18, 2021

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

The top patient safety strategies that can be encouraged for adoption now.

March 13, 2013

Missed opportunities for diagnosing brain tumours in primary care: a qualitative study of patient experiences.

April 3, 2019

Advancing the science of patient safety.

May 25, 2011

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit.

June 13, 2012

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

The morbidity and mortality conference: opportunities for enhancing patient safety.

February 9, 2022

Using simulation to improve patient safety: dawn of a new era.

March 18, 2015

Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs.

October 4, 2017

The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted time series analysis.

October 12, 2022

The effects of stress and coping on surgical performance during simulations.

January 13, 2010

Associations between safety outcomes and communication practices among pediatric nurses in the United States.

January 19, 2022

Emotional harm in the radiology department: analysis of an underrecognized preventable error.

February 9, 2022

Communication-and-resolution programs: the challenges and lessons learned from six early adopters.

January 15, 2014

Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.

May 29, 2019

Safe use of electronic health records and health information technology systems: trust but verify.

December 18, 2013

Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits.

July 10, 2017

Operative team communication during simulated emergencies: too busy to respond?

December 21, 2016

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

February 3, 2016

Does incorporating medications in the surveyors' interpretive guidelines reduce the use of potentially inappropriate medications in nursing homes?

July 4, 2007

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

January 20, 2016

Related Resources

Medication errors in pediatric emergency departments: a systematic review and recommendations for enhancing medication safety.

March 20, 2024

Medication safety gaps in English pediatric inpatient units: an exploration using work domain analysis.

March 6, 2024

Nurses' perspectives on medication errors and prevention strategies in residential aged care facilities through a national survey.

December 20, 2023

WebM&M Cases

Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose

October 31, 2023

A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large academic medical center.

August 2, 2023

Incivility in healthcare: the impact of poor communication.

August 2, 2023

Assessing the impact of a new pediatric healthcare facility on medication administration: a human factors approach.

July 12, 2023

Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene.

June 14, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.

March 22, 2023

Patient Safety Innovations

Journal Article

Study

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

November 16, 2022

Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content.

November 16, 2022

Resident and nurse perspectives on the use of secure text messaging systems.

October 19, 2022

Reducing near miss medication events using an evidence-based approach.

July 27, 2022

Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.

June 22, 2022

Human factors analysis of latent safety threats in a pediatric critical care unit.

May 18, 2022

Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality.

April 20, 2022

Journal Article

Study

Patient Safety Innovations

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

April 7, 2022

Weight-based Medication Errors in Children.

February 16, 2022

Nursing interventions to reduce medication errors in paediatrics and neonates: systematic review and meta-analysis.

December 8, 2021

Pediatric transport safety collaborative: adverse events with parental presence during pediatric critical care transport.

November 10, 2021

Medication dose calculation errors and other numeracy mishaps in hospitals: analysis of the nature and enablers of incident reports.

November 10, 2021

Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial.

October 13, 2021

Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review.

September 29, 2021

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children.

June 30, 2021

Fatal mistakes: why do ten-fold medication errors in children keep happening?

May 5, 2021

Effect of barcode technology on medication preparation safety: a quasi-experimental study.

April 14, 2021

A qualitative exploration of the impact of a distressed family member on pediatric resuscitation teams.

October 7, 2020

Pediatric trainees' speaking up about unprofessional behavior and traditional patient safety threats.

September 30, 2020

Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.

August 26, 2020

See More About The Topic

Medication Errors/Preventable Adverse Drug Events

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

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site