ABSTRACT
The purpose is to investigate the feasibility of predicting, identifying and mitigating latent system failures in a UK NHS paediatric hospital.
The study identified latent risks in a specific readily observable task set in a specialist paediatric hospital pharmacy department. Having identified a major latent risk, interruption, the investigation then established the significance that interruptions had on operatives, empirically. Mitigation was then devised and tested in another healthcare setting.
The research paradigm was predominantly Constructivism, that is the recognition that reality is a product of human intelligence interacting with experience in the real world. There is a problem generated by groups of individuals working in a real-world situation (Ontology). In order to understand this problem, the situation in which it occurs needs to be understood that is the underlying events and activities (Epistemology). The theoretical perspective could be said to be interpretivism and the methodology largely action research.
Interruptions were clearly demonstrated to be a latent system error, for what appears to have been the first time in healthcare research, and a mitigation devised and tested on another unrelated high-risk task that was IV medicine administration and was shown to reduce medicine errors
The theoretical basis included error causation theory, the functioning of short-term memory and how the brain manages multiple stimuli.
