title: Error analysis using organizational simulation.
abstract: Organizational simulations have been used by project organizations in civil and aerospace industries to identify work processes and organizational structures that are likely to fail under certain conditions. Using a simulation system based on Galbraith's information-processing theory and Simon's notion of bounded-rationality, we retrospectively modeled a chemotherapy administration error that occurred in a hospital setting. Our simulation suggested that when there is a high rate of unexpected events, the oncology fellow was differentially backlogged with work when compared with other organizational members. Alternative scenarios suggested that providing more knowledge resources to the oncology fellow improved her performance more effectively than adding additional staff to the organization. Although it is not possible to know whether this might have prevented the error, organizational simulation may be an effective tool to prospectively evaluate organizational "weak links", and explore alternative scenarios to correct potential organizational problems before they generate errors.
authors.affiliation: VA Palo Alto Health Care Systems, Palo Alto CA, USA. fridsma@stanford.edu
authors.forename: D B
authors.initials: DB
authors.lastname: Fridsma
mesh_terms: D002985:Clinical Protocols; D002986:Clinical Trials as Topic; D003198:Computer Simulation; D004358:Drug Therapy; D008495:Medical Oncology; D008508:Medication Errors / Q000517:prevention & control; D017146:Models, Organizational; D016522:Oncology Service, Hospital / Q000458:organization & administration*; D010561:Personnel Staffing and Scheduling; D012189:Retrospective Studies; D000078329:Workforce