Understanding complexity in a safety critical setting: A systems approach to medication administration.

'Medication errors' are a significant concern and are associated with a higher incidence of adverse events and unintentional patient harm than any other aspect of healthcare. While much research has focused on adverse medication errors, limited studies have specifically examined 'normal' medication delivery performance and the interactions between tasks, agents, and information within the medication administration system. This article describes a study that applied the Event Analysis of Systemic Teamwork (EAST) model to study the hospital medication administration system to identify opportunities to optimise performance and patient safety.

The impact of power on health care team performance and patient safety: a review of the literature.

Communication failure within health care teams is a major cause of patient harm across health care settings. Factors which contribute to communication failure include actual or perceived 'power'. Whilst a great deal of ergonomics research has focussed on teamwork in health care, the role of power in relation to measurable patient safety and performance outcomes remains relatively unknown.

Walking the talk: Comparing pedestrian 'activity as imagined' with 'activity as done'.

The safety of vulnerable road users, including pedestrians, is an important issue worldwide. In line with the shift towards systems thinking in transport safety, the aim of this study was to compare the normal performance of pedestrians as they navigate the road system with that imagined by road system managers to gain insights into how safety management can be improved for this vulnerable road user group. The Event Analysis of Systemic Teamwork framework was used to compare pedestrian activity 'as imagined' and 'as done' at signalised road intersections and railway level crossings.