Using variance analysis to detect hazards in a bar-code-assisted medication preparation process.
BACKGROUND
Medication errors have received significant attention, with studies pinpointing problems in the physician ordering, pharmacy dispensing, and nurse administering processes. Yet, the nursing process for preparing medications, which typically occurs in a medication room on the unit, has not received much attention. This process is deceptively complex, and without proper design, it could break down at numerous points.
Prospective hazard analysis methods allow the detection of potential hazards during the planning, assessment, and design phases of a process or technology. A specific technique-variance analysis-is used within one type of prospective hazard analysis, the sociotechnical systems analysis (STSA). STSA provides guidance to (1) analyze existing or planned systems to understand the social, technical, and environmental system components; (2) collect and analyze the system data; and (3) use the analysis to design or redesign the system.


CONCLUSIONS
The STSA variance analysis is an additional tool that health care clinicians, administrators, and risk managers can use to proactively identify hazards for control. Although this larger analysis is more time consuming, it forces the analysts to conduct a true systems analysis before implementing technical, social, environmental, or organizational changes.
Escoto
Kamisha Hamilton
KH
Department of Industrial Engineering, University of Wisconsin-Madison, USA.
Hallock
Melissa
M
Wagner
Jennifer
J
Karsh
Ben-Tzion
BT
D000704:Analysis of Variance; D001330:Electronic Data Processing; D006804:Ergonomics / Q000379:methods*; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D008510:Medication Systems, Hospital; D009736:Nursing Process; D016016:Proportional Hazards Models; D012308:Risk Management / Q000379:methods*; D013597:Systems Analysis