IntroductionIntravenous medication administration has traditionally been regarded as error prone, with high potential for harm. A recent US multisite study revealed few potentially harmful errors despite a high overall error rate. However, there is limited evidence about infusion practices in England and how they relate to prevalence and types of error.ObjectivesTo determine the prevalence, types and severity of errors and discrepancies in infusion administration in English hospitals, and to explore sources of variation, including the contribution of smart pumps.MethodsWe conducted an observational point prevalence study of intravenous infusions in 16 National Health Service hospital trusts. Observers compared each infusion against the medication order and local policy. Deviations were classified as errors or discrepancies based on their potential for patient harm. Contextual issues and reasons for deviations were explored qualitatively during observer debriefs.ResultsData were collected from 1326 patients and 2008 infusions. Errors were observed in 231 infusions (11.5%, 95% CI 10.2% to 13.0%). Discrepancies were observed in 1065 infusions (53.0%, 95% CI 50.8% to 55.2%). Twenty-three errors (1.1% of all infusions) were considered potentially harmful; none were judged likely to prolong hospital stay or result in long-term harm. Types and prevalence of errors and discrepancies varied widely among trusts, as did local policies. Deviations from medication orders and local policies were sometimes made for efficiency or patient need. Smart pumps, as currently implemented, had little effect, with similar error rates observed in infusions delivered with and without a smart pump (10.3% vs 10.8%, p=0.8).ConclusionErrors and discrepancies are relatively common in everyday infusion administrations but most have low potential for patient harm. Better understanding of performance variability to strategically manage risk may be a more helpful tactic than striving to eliminate all deviations.

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Abstract. Distributed Cognition is growing in popularity as a way of reasoning about group working and the design of artefacts within work systems. DiCoT (Distributed Cognition for Teamwork) is a methodology and representational system we are developing to support distributed cognition analysis of small team working. It draws on ideas from Contextual Design, but re-orients them towards the principles that are central to Distributed Cognition. When used to reason about possible changes to the design of a system, it also draws on Claims Analysis to reason about the likely effects of changes from a Distributed Cognition perspective. The approach has been developed and tested within a large, busy ambulance control centre. It supports reasoning about both existing system design and possible future designs.

Emergency medical dispatch (EMD) is typically a team activity, requiring fluid coordination and communication between team members. Such working situations have often been described in terms of distributed cognition (DC), a framework for understanding team working. DC takes account of factors such as shared representations and artefacts to support reasoning about team working. Although the language of DC has been developed over several years, little attention has been paid to developing a methodology or reusable representation which supports reasoning about an interactive system from a DC perspective. We present a case study in which we developed a method for constructing a DC account of team working in the domain of EMD, focusing on the use of the method for describing an existing EMD work system, identifying sources of weakness in that system, and reasoning about the likely consequences of redesign of the system. The resulting DC descriptions have yielded new insights into the design of EMD work and of tools to support that work within a large EMD centre.