To investigate the feasibility of predicting, identifying and mitigating latent system failures in a UK NHS paediatric hospital

  • Anthony Sinclair

Student thesis: Doctoral ThesisDoctor of Philosophy


The aim of this study was to investigate the feasibility of identifying latent system failures in a paediatric National Health Service hospital in the England (NHS). Medicine related errors affect up to 9% of all patients in NHS hospitals.
The theoretical basis included error causation theory, the functioning of short-term memory and how the brain manages multiple stimuli. The literature review covered error causation and prevention research, undertaken in healthcare settings and other high-risk industries. The study environment was the dispensary of Birmingham Children’s Hospital (BCH) and a busy ward. The study instrument was non-participant, direct observation of routine dispensing and medicines administration tasks.
The first phase 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. The second phase investigated the efficiency and effectiveness of the current Incident and error reporting system (IR1s) in supporting learning from incidents and changing practice.
The first phase identified “interruptions” as a latent error and demonstrated, for what appears to have been the first time in healthcare research, the impact these have on operatives. The second phase confirmed that a gap existed in healthcare error reduction strategies. From the outcomes of the first two phases a completely new strategy, to predict latent system errors and then to reduce them was devised. The strategy was then implemented in another area of the hospital, with different staff, on a high-risk task, IV medicine administration and was shown to reduce medicine errors.
Date of Award2016
Original languageEnglish
SupervisorKeith A Wilson (Supervisor) & Prasanta Dey (Supervisor)


  • medicine incidents
  • error causation
  • efficiency
  • incident reporting
  • interruptions
  • learning organization
  • latent system failures
  • quality management systems
  • memory
  • multitasking
  • non-professionalism
  • patient safety
  • paediatric pharmacy
  • professionalism
  • risk management

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