Safety in Hospital Medication Administration Applying STAMP Processes
Repeated application of root cause analysis techniques has not led to significant hospital medication administration safety improvements. The healthcare industry has begun to draw on scientific approaches to safety from outside traditional medical fields, including human factors engineering and syst...
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| Format: | Thesis |
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Massachusetts Institute of Technology
2022
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| Online Access: | https://hdl.handle.net/1721.1/143213 |
| Summary: | Repeated application of root cause analysis techniques has not led to significant hospital medication administration safety improvements. The healthcare industry has begun to draw on scientific approaches to safety from outside traditional medical fields, including human factors engineering and systems design. This thesis lays the foundation to advance quality hospital healthcare for patients and providers by reducing hospital medication errors and enhancing hospital safety practices using STAMP techniques.
A CAST analysis is performed for a frequently occurring hospital medication administration error to demonstrate the power of avoiding future losses through causal analysis based on systems theory compared to root cause analysis techniques. An STPA hazard analysis for hospital medication administration is also performed. The current hospital safety management system is analyzed, highlighting gaps where applying STAMP analysis to the hospital organization structure would enhance the safety within the hospital organization at large. Potential future directions in healthcare safety engineering are discussed. |
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