Understanding complexity in a safety critical setting: A systems approach to medication administration.
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| Title: | Understanding complexity in a safety critical setting: A systems approach to medication administration. |
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| Authors: | Stevens, Erin L.1 erin.stevens@research.usc.edu.au, Hulme, Adam2, Goode, Natassia3, Coventon, Lauren1, Read, Gemma1, Salmon, Paul M.1 |
| Source: | Applied Ergonomics. Jul2023, Vol. 110, pN.PAG-N.PAG. 1p. |
| Subjects: | Medication errors, Medical care, Patient safety, Medical personnel, Social networks |
| Abstract: | 'Medication errors' are a significant concern and are associated with a higher incidence of adverse events and unintentional patient harm than any other aspect of healthcare. While much research has focused on adverse medication errors, limited studies have specifically examined 'normal' medication delivery performance and the interactions between tasks, agents, and information within the medication administration system. This article describes a study that applied the Event Analysis of Systemic Teamwork (EAST) model to study the hospital medication administration system to identify opportunities to optimise performance and patient safety. Key findings of this study demonstrate that this is a highly complex system, comprising many social agents and a relatively closely linked series of tasks and information. However, most of the workload relies on a small proportion of healthcare professionals. Significantly, the patient has a minimal role in the medication administration system during their hospital stay. The research has shown that this approach enables mapping networks and their interdependencies to optimise the system as a whole rather than its parts in isolation. • Novel application of a systems approach to medication administration processes, beyond error prevention and management. • Development of the Event Analysis of Systemic Teamwork (EAST) model to describe task, social, and information networks. • Main findings demonstrate the limited shared communications across all the networks, particularly the socialnetwork. • Future research and practice implications for the optimisation of healthcare team performance and patient safety. [ABSTRACT FROM AUTHOR] |
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| Database: | Engineering Source |
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