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

Area of Science:

• Healthcare systems engineering
• Patient safety research
• Clinical risk management

Background:

• Medication errors in the operating room occur frequently (4-10%) but are poorly understood prospectively.
• Systems theoretic process analysis (STPA) is a risk assessment technique using systems theory to identify hazards.
• Few studies have prospectively modeled the causes of operating room medication errors.

Purpose of the Study:

• To demonstrate the application of STPA in a healthcare setting.
• To prospectively identify causal factors contributing to medication errors in the operating room.
• To analyze the medication use process within the operating room.

Main Methods:

• A hierarchical control structure of the operating room medication system was developed.
• STPA was used to identify unsafe control actions and causal scenarios.
• Input was gathered from surgeons, anesthesiologists, and pharmacists.

Main Results:

• The analysis identified 342 causal scenarios for medication errors.
• Unsafe control actions were linked to various levels of the control structure.
• The majority of scenarios (45.9%) originated from the execution of patient care level.

Conclusions:

• STPA effectively identified potential causes of medication errors in the operating room.
• Causal scenarios spanned from frontline providers to senior management.
• STPA is valuable for quality improvement by analyzing management and leadership influences.