Table 3.

Themes and categories identified from the interviews

Theme	Categories	Examples
Individual factors	Inexperience. Lack of skills or knowledge.	Inexperienced in paediatric prescribing (eg, an adult anaesthetist on a short rotation).
Organisational factors	Divergent practice and systems. Conflicting priorities.	Different protocols between patients receiving non-intensive care unit (ICU) care (postoperative recovery) and those receiving ICU care.
Task-related factors	Ambiguous or inaccessible information. Reliance on memory and previous experience. Problem recognition. Task complexity.	Inability to locate guidelines and procedures on the intranet because of a lack of computer facilities.
Team-related factors	Flat hierarchy. Leadership and support. Verbal communication.	Lack of handover related to medicines that the patient is receiving on admission.
Work-related factors	Distraction and interruption. Prioritisation.	Rewriting a complex medication chart and being asked to review blood gases, or answer the telephone.