Medication safety gaps in English pediatric inpatient units: An exploration using work domain analysis (January 2024)

Summary

Medication is a common cause of preventable medical harm in paediatric inpatients. This study aimed to examine the sociotechnical system surrounding paediatric medicines management and to identify potential gaps in this system and how these might contribute to adverse drug events (ADEs).

The authors advocate the following actions as a result of the insights gained about contributing factors to ADEs:

• processes to involve parents in the care of their children in hospital.
• development of skill-mix interventions to ensure appropriate expertise is available where it is needed.
• modified checking procedures to permit staff to use their skills and judgment effectively and efficiently.