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How predictable are paediatric errors in paediatric hospitals Anthony Sinclair. To Investigate the feasibility of identifying latent errors in a system and as a result identify potential errors prospectively.
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How predictable are paediatric errors in paediatric hospitalsAnthony Sinclair
To Investigate the feasibility of identifying latent errors in a system and as a result identify potential errors prospectively.
The study environment was the dispensary of Birmingham Children’s Hospital (BCH), a tertiary referral Children’s Hospital. Method • Questionnaires • Observation • Non-participant direct observation of the accuracy checking step of the dispensing process • Technicians (n=9), Pharmacists (n=9) • Interviews • Focus groups
Results-Questionnaires A link exists between making errors and the working environment. • Respondents felt stressed one session in three, when they were five times more likely to make an error than on other occasions.
Results- The Observations As work load increased The average time taken to accuracy check an item decreased for the technician group and increased for the pharmacist group • The number of steps taken to check an item varied with workload. • Decreasing for the technician group • Increasing for the pharmacist group. • The number of Safety steps also varied with increasing work load Decreasing for the pharmacist group • Increasing for the Technician group. • The number of safety steps that the Pharmacist group performed was higher overall when compared with the technician group.
Results- The Interviews and Focus groups Keythemes Pressure to work faster Noise Training and procedures Workplace design Interruptions Emotions Paperwork design
Finally - significant themes Error outcomes or Error causation Workplace design Workload capacity Individual training
Next Steps To measure the impact that interruptions have on individual effectiveness To determine whether working to a checking protocol reduces error rates. To develop an evidenced based aseptics accuracy checking competency.
Anthony Sinclair Chief Pharmacist Birmingham Children’s Hospital NHS Foundation Trust Researching for a PhD at Aston University anthony.sinclair@bch.nhs.uk