Use of Systems-Theoretic Process Analysis to Design Safer Opioid Prescribing Processes

Abstract

OCCUPATIONAL APPLICATIONSA team of systems engineers, clinicians, and healthcare researchers evaluated the Systems-Theoretic Process Analysis (STPA) method to analyze and design a process to ensure safe opioid prescribing at an urban primary care clinic. The STPA framework of losses, hazards, and controls identified two major unacceptable losses, 10 hazards related to these losses, and 49 unsafe control actions. These analyses resulted in 16 suggested process improvements encompassing both technology and human elements. Although STPA captured the complex system of controls and feedback inherent in many healthcare processes, and shows strong potential to help redesign them, providers generally found the method to be somewhat overwhelming due to the time required, large amount of information generated, and divergence from traditional and simpler linear causality thinking. While the suggested process changes were direct and specific, stakeholders believe that some may be difficult to implement without significant upper-level management support.