A participatory systems approach for patient safety: Mapping practitioners’ insights in medication journey improvement

Medication errors represent a critical patient safety challenge that requires systems-level interventions to address complex interactions among people, processes, technologies, and organizational guidelines. This study used a participatory systems approach to gain experts’ insights into enhancing medication safety. Twenty-six pharmacists and pharmacy managers from the United Arab Emirates participated in a structured workshop that used the Improvement Canvas framework. Participants explored eight domains of improvement: understanding context, defining problems, identifying stakeholders, developing solutions, collecting evidence, building teams, making the case for change, and managing implementation. The findings of the workshop were analyzed using thematic analysis and interpreted through the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 framework. Participants consistently highlighted verification as a key control point and identified interacting factors spanning clinical roles, workflows, technologies, organizational practices, and monitoring processes. Participant-generated ideas included standardized units, verification, automated dispensing with human oversight, real-time monitoring dashboards, and AI-supported decision-support or follow-up tools. These findings informed practitioner-informed recommendations for improving medication safety across the medication-use journey. A supplementary usability assessment suggested acceptable perceived usability of the workshop toolkit (mean SUS = 68.5). Overall, the study illustrates how participatory systems workshops can emphasize work-as-done insights and how SEIPS 3.0 can support their structured interpretation for medication safety improvement