Zobraziť v EDS

Learning from workarounds in barcode medication administration: a Safety-II perspective.

Uložené v:
Podrobná bibliografia
Názov: Learning from workarounds in barcode medication administration: a Safety-II perspective.
Autori: Cossul D; Industrial Engineering Post-Graduate Program, Universidade Federal do Rio Grande do Sul, Brazil. Electronic address: danielli.cossul@ufrgs.br., Saurin TA; Industrial Engineering Post-Graduate Program, Universidade Federal do Rio Grande do Sul, Brazil. Electronic address: saurin@ufrgs.br., da Silva Fraga R; Hospital de Clínicas de Porto Alegre, Brazil. Electronic address: rofsilva@hcpa.edu.br., Pasin SS; Hospital de Clínicas de Porto Alegre, Brazil. Electronic address: spasin@hcpa.edu.br., de Souza Kuchenbecker R; Hospital de Clínicas de Porto Alegre, Brazil. Electronic address: rkuchenbecker@hcpa.edu.br.
Zdroj: Applied ergonomics [Appl Ergon] 2025 Nov; Vol. 129, pp. 104605. Date of Electronic Publication: 2025 Jul 25.
Spôsob vydávania: Journal Article
Jazyk: English
Informácie o časopise: Publisher: Butterworth-Heinemann Country of Publication: England NLM ID: 0261412 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1872-9126 (Electronic) Linking ISSN: 00036870 NLM ISO Abbreviation: Appl Ergon Subsets: MEDLINE
Imprint Name(s): Publication: Oxford : Butterworth-Heinemann
Original Publication: London.
Výrazy zo slovníka MeSH: Medication Systems, Hospital*/organization & administration , Safety Management* , Electronic Data Processing*, Humans ; Focus Groups ; Medication Errors/prevention & control ; Patient Safety ; Guidelines as Topic ; Male ; Learning ; Female
Abstrakt: Competing Interests: Conflict of interest On behalf of all my co-authors I declare no conflict of interest related to our submission to Applied Ergonomics, entitled Learning from workarounds in barcode medication administration: a Safety-II perspective.
Workarounds (WAs) in healthcare digital technologies are common, and several coping measures have been proposed. However, prior studies did not emphasize how to learn from WAs, which should be the basis for any improvement. This study addresses this gap by introducing guidelines to learn from WAs. The guidelines are underpinned by the Safety-II perspective, which recognizes that WAs are context-dependent and have mixed outcomes. A case study of barcode medication administration in a large hospital provides the empirical foundation for the guidelines. Data collection encompassed documentary analysis, shadowing of caregivers, interviews, focus groups, a survey for assessing risks of WAs, and a psychological safety survey. Results revealed 22 WAs, 43 contributing factors, nine potential desired outcomes and nine potential undesired outcomes. Tackling the contributing factors is crucial to reduce the frequency and risks associated with WAs. Five learning guidelines emerged, addressing: (i) prioritization of WAs based on their risk; (ii) emphasis on risk reduction rather than elimination; (iii) data-driven focus groups; (iv) limitations of WAs as a source of learning; and (v) use of language consistent with Safety-II; this guideline is accompanied by a new WA definition. These guidelines might inform the design of learning systems supportive of resilient healthcare.
(Copyright © 2025 Elsevier Ltd. All rights reserved.)
Contributed Indexing: Keywords: Barcode medication; Health services; Learning; Safety-II; Workarounds
Entry Date(s): Date Created: 20250727 Date Completed: 20250910 Latest Revision: 20250910
Update Code: 20250911
DOI: 10.1016/j.apergo.2025.104605
PMID: 40714399
Databáza: MEDLINE
Popis
Abstrakt:Competing Interests: Conflict of interest On behalf of all my co-authors I declare no conflict of interest related to our submission to Applied Ergonomics, entitled Learning from workarounds in barcode medication administration: a Safety-II perspective.<br />Workarounds (WAs) in healthcare digital technologies are common, and several coping measures have been proposed. However, prior studies did not emphasize how to learn from WAs, which should be the basis for any improvement. This study addresses this gap by introducing guidelines to learn from WAs. The guidelines are underpinned by the Safety-II perspective, which recognizes that WAs are context-dependent and have mixed outcomes. A case study of barcode medication administration in a large hospital provides the empirical foundation for the guidelines. Data collection encompassed documentary analysis, shadowing of caregivers, interviews, focus groups, a survey for assessing risks of WAs, and a psychological safety survey. Results revealed 22 WAs, 43 contributing factors, nine potential desired outcomes and nine potential undesired outcomes. Tackling the contributing factors is crucial to reduce the frequency and risks associated with WAs. Five learning guidelines emerged, addressing: (i) prioritization of WAs based on their risk; (ii) emphasis on risk reduction rather than elimination; (iii) data-driven focus groups; (iv) limitations of WAs as a source of learning; and (v) use of language consistent with Safety-II; this guideline is accompanied by a new WA definition. These guidelines might inform the design of learning systems supportive of resilient healthcare.<br /> (Copyright © 2025 Elsevier Ltd. All rights reserved.)
ISSN:1872-9126
DOI:10.1016/j.apergo.2025.104605