Enhancing healthcare resilience: systemic medication errors debate in emergency departments with Soft System Methodology.

IF 1.1 4区 医学 Q4 PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH
Ciencia & saude coletiva Pub Date : 2025-06-01 Epub Date: 2025-02-21 DOI:10.1590/1413-81232025306.20912024
Flávia Silva de Souza, Ana Carolina Sanches Zeferino, Rebecca Thaffenne Santos Oliveira Nunes, Célio Manso de Azevedo Junior, Níssia Carvalho Rosa Bergiante
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引用次数: 0

Abstract

The effective management of medications is a critical component of a resilient healthcare system, directly impacting patient health outcomes. However, its complexity can lead to errors, compromising patient safety and treatment efficacy. Through exploratory and qualitative action research, utilizing data from secondary sources and interviews with the medication management team, Soft Systems Methodology (SSM) was employed in three stages. Using CATWOE (Customers, Actors, Transformation, Worldview, Owner e Environmental) framework, seven transformations were defined, with systemic propositions developed for four of them, namely, improving prescription readability, adjusting the medication procurement process to demand, enhancing working conditions, and optimizing team experience. These propositions involved the analysis of their causes and mitigating measures. By emphasizing a collaborative approach and seeking integrated solutions, SSM proved to be instrumental in achieving system resilience.

增强医疗弹性:用软系统方法讨论急诊科的系统性用药错误。
有效的药物管理是弹性医疗保健系统的关键组成部分,直接影响患者的健康结果。然而,其复杂性可能导致错误,危及患者安全和治疗效果。通过探索性和定性的行动研究,利用二手资料和与用药管理团队的访谈,采用软系统方法论(SSM)分为三个阶段。采用CATWOE (Customers, Actors, Transformation, Worldview, Owner e environment)框架,定义了7个转型,并针对其中4个转型提出了系统命题,即提高处方可读性、调整药品采购流程以适应需求、改善工作条件、优化团队体验。这些主张涉及对其原因和缓解措施的分析。通过强调协作方法和寻求集成解决方案,SSM被证明是实现系统弹性的工具。
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来源期刊
Ciencia & saude coletiva
Ciencia & saude coletiva PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH-
CiteScore
3.60
自引率
11.80%
发文量
533
审稿时长
12 weeks
期刊介绍: Ciência & Saúde Coletiva publishes debates, analyses, and results of research on a Specific Theme considered current and relevant to the field of Collective Health. Its abbreviated title is Ciênc. saúde coletiva, which should be used in bibliographies, footnotes and bibliographical references and strips.
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