ABSTRACT
Systems perspective and systems design are important for medication safety across the entire medication use process. This chapter will dene the systems perspective from a human factors engineering viewpoint and consider the six major systems features in relation to medication safety: systems focus, interactions between systems elements, contextual issues, the whole-person perspective (“holism”), safety as an emergent property, and embedding of human factors/ergonomics-trained
Key Points .............................................................................................................. 109 Introduction ............................................................................................................ 109 Systems and Systems Approaches ......................................................................... 110
Systems Focus ................................................................................................... 111 Interactions ........................................................................................................ 114 Context .............................................................................................................. 117 Holism ............................................................................................................... 118 Emergence ......................................................................................................... 119 Embedding ........................................................................................................ 120
Medication Safety Examples ................................................................................. 121 Implementation of Smart IV Infusion Pumps ................................................... 121 Implementation of Computerized Prescriber Order Entry Technology ............ 122
Conclusion ............................................................................................................. 122
professionals into health care organizations as a safety strategy (Wilson 2014). We will highlight how system design aws can lead to unanticipated medication errors and how human factors approaches can proactively identify and reduce or eliminate the hazards leading to these errors. Lastly, we will discuss two case examples of health care information technology (IT) implementations and how they benetted from the application of the systems perspective.
