Using Probablilistic Risk Assessment to Model Medication System Failures in Long-Term Care Facilities
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY ROCKVILLE MD
Pagination or Media Count:
Objective State agencies and Oregons long-term care providers cosponsored this developmental study to explore the creation of two statewide medication system risk models using sociotechnical probabilistic risk assessment ST-PRA. This paper summarizes the methodology involved in this ongoing project. Methods A convenience sample of 18 facilities participated. Seven multidisciplinary modeling teams used process mapping, control system mapping, modified failure modes and effects analysis, and ST-PRA to create consolidated ST-PRA models, one for nursing facilities and one for community-based care CBC i.e., residential careassisted living facilities. Discussion The models provide contextual maps of the errors and behaviors that lead to medication delivery system failures, including unanticipated risks associated with regulatory practices and common deviations from policies and procedures. Policymakers, regulators, and managers can identify, prioritize, and prospectively model risk reduction interventions using ST-PRA. Conclusion ST-PRA models can identify systemic and behavioral elements that increase or reduce the risk of wrong-drug, wrong-dose, omitted-dose or drug, and wrong-patient medication administration errors in nursing and CBC facilities.
- Medicine and Medical Research
- Medical Facilities, Equipment and Supplies
- Statistics and Probability
- Computer Programming and Software