Exploring Medication Safety in the Pediatric Intensive Care Unit Through a Human Factor Lens

Introduction: Medication errors are among the most reported adverse events (AE) in Canadian hospitals, contributing significantly to iatrogenic and preventable morbidity. Human factors (HF) models offer better understanding of and design for operator performance and safety in complex systems. The use of HF methods to identify contributory system factors facilitates intervention design, quality improvement, and a just culture.


Methods: This is an exploratory qualitative study of medication-related safety events reported by ICU staff at an urban free-standing quaternary children’s hospital.

One hundred four medication-related AE and near misses were reported during the study period (May 2022-Oct 2023) via the site’s ‘Reporting and Learning System’; 88 were included in analysis. Reports were coded inductively using a modified Framework Method to categorize events by associated medication “wrong” (ie, drug, dose, time, route, documentation, patient, reason), work system element (ie, task, tool/technology, people, organization, physical environment), and process (ie, prescription, order, dispensation, preparation, administration).


Results: Most reported medication events involved a “Dose” wrong (n=54, 50%). All work system elements contributed to medication events, most commonly “Task” (n=59, 55%), followed by “Tool/Technology” (n=18, 17%), “Organization” (n=18, 17%), “People” (n=7, 7%), and “Physical” (n=5, 5%). “Preparation” (n=41, 38%) was the most implicated process, followed by "Dispensation” (n=23, 21%), “Order” (n=21, 20%), “Administration” (n=14, 13%), and “Prescription” (n=8, 7%). Most reported medication events resulted in no patient harm (27% near miss, 43% no harm events).


Conclusions: Medication events occurred in every work process due to myriad system elements, highlighting the complexity of the PICU and importance of designing interventions to address local system factors underlying human error. From our sample, medication “Preparation” was the most error-prone process, and errors were most commonly the result of “Task” factors (ie, the characteristics of specific actions to execute a process, such as urgency, complexity, variety, ambiguity, and sequence), thus next steps in system-level intervention design will focus on addressing task complexity in medication preparation.