Enhancing healthcare resilience: systemic medication errors debate in emergency departments with Soft System Methodology

The effective management of medications is a critical component of a resilient healthcare system, directly impacting patient health outcomes. However, its complexity can lead to errors, compromising patient safety and treatment efficacy. Through exploratory and qualitative action research, utilizing data from secondary sources and interviews with the medication management team, Soft Systems Methodology (SSM) was employed in three stages. Using CATWOE (Customers, Actors, Transformation, Worldview, Owner e Environmental) framework, seven transformations were defined, with systemic propositions developed for four of them, namely, improving prescription readability, adjusting the medication procurement process to demand, enhancing working conditions, and optimizing team experience. These propositions involved the analysis of their causes and mitigating measures. By emphasizing a collaborative approach and seeking integrated solutions, SSM proved to be instrumental in achieving system resilience.