Send to

Choose Destination
Arch Dis Child. 2019 Feb 8. pii: archdischild-2018-315981. doi: 10.1136/archdischild-2018-315981. [Epub ahead of print]

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

Author information

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.
Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Science Centre (MAHSC), Manchester, UK.



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.


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.


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.


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.


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

Conflict of interest statement

Competing interests: None declared.

Supplemental Content

Full text links

Icon for HighWire
Loading ...
Support Center