A Systems Theoretic Process Analysis of the Medication Use Process in the Operating Room

Conclusions In this study, the authors demonstrated the use of systems theoretic process analysis to describe potential causes of errors in the medication use process in the operating room. Causal scenarios were linked to controllers ranging from the frontline providers up to the highest levels of perioperative management. Systems theoretic process analysis is uniquely able to analyze management and leadership impacts on the system, making it useful for guiding quality improvement initiatives.Editor ’s PerspectiveWhat We Already Know about This TopicMedication error in the operating room is commonSystems theoretic process analysis is a prospective engineering modeling technique that uses systems theory to identify hazardsWhat This Article Tells Us That Is NewA systems theoretic process analysis identified unsafe control actions linked to causal scenarios that could lead to medication errorsScenarios came from perioperative leadership, management of patient care, and execution of patient care
Source: Anesthesiology - Category: Anesthesiology Source Type: research