1. How predictable are paediatric errors in paediatric hospitals Anthony Sinclair

2. To Investigate the feasibility of identifying latent errors in a system and as a result identify potential errors prospectively.

3. The study environment was the dispensary of Birmingham Children’s Hospital (BCH), a tertiary referral Children’s Hospital. Questionnaires Interviews Focus groups  Observation o Non-participant direct observation of the accuracy checking step of the dispensing process o Technicians (n=9), Pharmacists (n=9) Method

4. 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.

5. 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 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. The number of steps taken to check an item varied with workload. Decreasing for the technician group Increasing for the pharmacist group.

6. Results- The Interviews and Focus groups Key themes Pressure to work faster Noise Training and procedures Workplace design Interruptions Emotions Paperwork design

7. Finally - significant themes Error outcomes or Error causation Workplace design Workload capacity Individual training

8. Next Steps To determine whether working to a checking protocol reduces error rates. To measure the impact that interruptions have on individual effectiveness To develop an evidenced based aseptics accuracy checking competency.

9. Anthony Sinclair Chief Pharmacist Birmingham Children’s Hospital NHS Foundation Trust Researching for a PhD at Aston University anthony.sinclair@bch.nhs.uk