Understanding complexity in a safety critical setting: A systems approach to medication administration

Erin L. Stevens; Adam Hulme; Natassia Goode; Lauren Coventon; Gemma Read; Paul M. Salmon

doi:10.1016/j.apergo.2023.104000

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Understanding complexity in a safety critical setting: A systems approach to medication administration

Journal article

Peer reviewed

Understanding complexity in a safety critical setting: A systems approach to medication administration

Erin L. Stevens, Adam Hulme, Natassia Goode, Lauren Coventon, Gemma Read and Paul M. Salmon

Applied Ergonomics, Vol.110, pp.1-39

2023

DOI: https://doi.org/10.1016/j.apergo.2023.104000

PMID: 36958252

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Abstract

Event analysis of systemic teamwork

Medication administration system

Patient safety

‘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.

Details

Title: Understanding complexity in a safety critical setting: A systems approach to medication administration
Authors: Erin L. Stevens (Corresponding Author) - University of the Sunshine Coast, Queensland, School of Law and Society
Adam Hulme (Author) - The University of Queensland
Natassia Goode (Author) - WorkSafe Victoria
Lauren Coventon (Author) - University of the Sunshine Coast, Queensland, Centre for Human Factors and Systems Science
Gemma Read (Author) - University of the Sunshine Coast, Queensland, School of Law and Society
Paul M. Salmon (Author) - University of the Sunshine Coast, Queensland, Centre for Human Factors and Systems Science
Publication details: Applied Ergonomics, Vol.110, pp.1-39
Publisher: Elsevier Ltd
Date published: 2023
DOI: 10.1016/j.apergo.2023.104000
ISSN: 1872-9126
PMID: 36958252
Organisation Unit: Centre for Human Factors and Systems Science; University of the Sunshine Coast, Queensland; School of Health - Psychology; School of Law and Society
Language: English
Record Identifier: 99715098602621
Output Type: Journal article

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Collaboration types: Domestic collaboration
Web Of Science research areas: Engineering, Industrial; Ergonomics; Psychology, Applied

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