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Developing a climate for safe prescribing for children
  1. Richard L Conn1,2,
  2. Eleftheria Ainley2
  1. 1 Centre for Medical Education, Queen's University Belfast, Belfast, UK
  2. 2 Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
  1. Correspondence to Dr Richard L Conn, Centre for Medical Education, Queen's University Belfast, Belfast BT9 7BL, UK; r.conn{at}

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Key messages

  • Evidence shows that prescribing errors have multiple complex causes, so improving safety is less about training individuals and more about creating a safer prescribing climate.

  • Familiar interventions can be effective but practitioners should adapt them to their context and stay alert to the impact of workplace culture.

  • Implementation science offers tools and approaches to help evaluate, refine and share solutions to complex problems like safe prescribing.


How do you solve a problem like prescribing? Prescribing error—a foremost threat to paediatric safety1—has been studied (eg, multicentre research quantifying prevalence and types),2 clarified (eg, by elucidating factors that complicate prescribing for children)3 and prioritised within policy, quality improvement and education.1 Instances of successful and innovative interventions4 have been published, but prescribing safety remains elusive.5 This begs these questions: Should we look at the problem differently? How can education better address it? How should we implement and share innovations? We address these questions by proposing that prescribing safety is a complex problem, reviewing how familiar interventions can improve environments for safe prescribing and showing how implementation science could contribute.


The word ‘complex’ has a specific meaning: that no single factor alone causes harm. Because multiple factors interact unpredictably, prescriptions intended to benefit children always carry a risk of error and harm. Improving safety when faced with complex problems is not about finding a single root cause, but understanding which factors are most important and how they interact. While this article focuses on error, complexity principles equally apply to learning from factors underlying safe prescribing—a Safety-II approach. Understanding complex systems leads to sometimes blindingly obvious solutions that pay unexpected dividends.

The 2009 EQUIP study confirmed that (adult) prescribing errors resulted from complexity, not just prescribers’ lack of knowledge. Social interactions, working conditions and culture played a major …

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  • Twitter @richardlconn, @EleftheriaMpou

  • Contributors RLC wrote the article, incorporating feedback and guidance from EA.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.