Centre for Human Factors and Sociotechnical Systems, School of Law and Society, University of the Sunshine Coast, Sippy Downs, 4558, Queensland, Australia.
Southern Queensland Rural Health, Faculty of Health and Behavioural Sciences, The University of Queensland, Toowoomba, 4350, Queensland, Australia.
Appl Ergon. 2023 Jul;110:104000. doi: 10.1016/j.apergo.2023.104000. Epub 2023 Mar 21.
'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.
“用药错误”是一个严重的问题，比医疗保健的任何其他方面都更易导致不良事件和非故意的患者伤害。虽然很多研究都集中在不良用药错误上，但很少有研究专门研究“正常”用药传递性能以及用药管理系统内任务、人员和信息之间的相互作用。本文描述了一项应用系统团队工作事件分析（EAST）模型来研究医院用药管理系统以确定优化性能和患者安全机会的研究。这项研究的主要发现表明，这是一个高度复杂的系统，包含许多社会人员以及相对紧密联系的一系列任务和信息。然而，大部分工作量依赖于一小部分医疗保健专业人员。重要的是，患者在住院期间在用药管理系统中几乎没有发挥作用。研究表明，这种方法可以对网络及其相互依存关系进行映射，以优化整个系统，而不是孤立地优化其各个部分。
