A Systems Theoretic Process Analysis of the Medication Use Process in the Operating Room

Anesthesiology. 2020 Aug;133(2):332-341. doi: 10.1097/ALN.0000000000003376.


Background: While 4 to 10% of medications administered in the operating room may involve an error, few investigations have prospectively modeled how these errors might occur. Systems theoretic process analysis is a prospective risk analysis technique that uses systems theory to identify hazards. The purpose of this study was to demonstrate the use of systems theoretic process analysis in a healthcare organization to prospectively identify causal factors for medication errors in the operating room.

Methods: The authors completed a systems theoretic process analysis for the medication use process in the operating room at their institution. First, the authors defined medication-related accidents (adverse medication events) and hazards and created a hierarchical control structure (a schematic representation of the operating room medication use system). Then the authors analyzed this structure for unsafe control actions and causal scenarios that could lead to medication errors, incorporating input from surgeons, anesthesiologists, and pharmacists. The authors studied the entire medication use process, including requesting medications, dispensing, preparing, administering, documenting, and monitoring patients for the effects. Results were reported using descriptive statistics.

Results: The hierarchical control structure involved three tiers of controllers: perioperative leadership; management of patient care by the attending anesthesiologist, surgeon, and pharmacist; and execution of patient care by the anesthesia clinician in the operating room. The authors identified 66 unsafe control actions linked to 342 causal scenarios that could lead to medication errors. Eighty-two (24.0%) scenarios came from perioperative leadership, 103 (30.1%) from management of patient care, and 157 (45.9%) from execution of patient care.

Conclusions: In this study, the authors demonstrated the use of systems theoretic process analysis to describe potential causes of errors in the medication use process in the operating room. Causal scenarios were linked to controllers ranging from the frontline providers up to the highest levels of perioperative management. Systems theoretic process analysis is uniquely able to analyze management and leadership impacts on the system, making it useful for guiding quality improvement initiatives.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Anesthesiologists / standards
  • Anesthesiology / standards*
  • Drug-Related Side Effects and Adverse Reactions / prevention & control*
  • Humans
  • Medication Errors / prevention & control*
  • Operating Rooms / methods
  • Operating Rooms / standards*
  • Pharmacists / standards
  • Prospective Studies
  • Quality Improvement / standards*
  • Surgeons / standards
  • Systems Theory*