Exploring medication errors and doctors’ and nurses’ perceptions of them in the Paediatric Intensive Care Unit (PICU).

Abstract

Despite the introduction of numerous strategies to improve medication safety, error rates over the last 5 years have not reduced. Moreover, some errors are being repeated. This suggests that staff may not learn from their errors or individual learning is not being shared across the PICU. The aim of this study was to gain a more accurate understanding of medication error (ME) occurrence in one large Paediatric Intensive Care Unit (PICU) and to explore the paediatric intensive care (PIC) team’s perceptions of MEs and how they perceive that they learn from them. An exploratory study using a parallel convergent mixed methods approach was chosen using both qualitative and quantitative method was chosen. Focus groups and interviews generated three overlapping core categories, which were linked by a meta-category, ‘the reality of practice’, which provided a means of synthesising the range of participants’ perceptions and practices. Interruptions and distractions were observed to increase violations of policy and protocol. There MEs were observed out of 59 medication administration episodes; none of these errors were reported formally, suggesting that MEs remain underreported. The content analysis of reflective learning tools highlighted a lack of detailed, self-analysis and reflection following an error to demonstrate learning.