ABSTRACT
Medication errors in pediatric patients arc well recognized and there is evidence that potentially harmful medication errors may be three times more common in the pediatric population than in adults. However, it is not clear where errors are most likely to occur in the sequence of prescription, dispensing, administration, and monitoring, and what factors contribute to their occurrence. The goal of this project was to understand the context and tasks associated with the administration of IV bolus morphine to pediatric patients. A human factors approach was adopted whereby the relationships between individuals, technology, artifacts, and the physical environment were studied. A total of 51 observations of morphine administrations were conducted in a post-surgical unit, all events and communications were captured, and then analyzed to identify a total of 75 influencing factors. Four major categories were identified: 1. Environmental, including interruptions, unexpected events, noise, work patterns, etc; 2. Tools, devices, and resources, including issues with information display, availability of critical information, equipment design,
etc.; 3. Operating characteristics, including fatigue, experience and risk-taking behaviors; and 4. Organizational and social factors, including communication, clarity of responsibilities, distribution of workload, etc. The findings suggest that the error-likely points in the process are more frequently related to environmental and/ or physical factors of the post-surgical care context.
