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Using Variance Analysis to Detect Hazards in a Bar-Code–Assisted Medication Preparation Process

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Abstract:

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.

Human Factors Engineering Analysis: 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.

Discussion: 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.

Document Type: Research Article

Publication date: 2004-11-01

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  • The Joint Commission Journal on Quality and Patient Safety will be published by Elsevier beginning in 2017! For readers who receive access to the journal through their institutions, the journal can now be found on ScienceDirect (http://www.sciencedirect.com/science/journal/15537250). For librarians looking to subscribe to the journal for their institutions please contact your Elsevier Account Manager or visit www.myelsevier.com for more information. All other readers, please visit http://www.jointcommissionjournal.com/ to subscribe to the journal or to claim your access for an existing subscription.
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