The development of a next-generation human reliability analysis: Systems analysis for formal pharmaceutical human reliability (SAFPHR)

Medication errors originating in community pharmacies are a serious patient safety hazard. However, due to the complexity of the community pharmacy environment, current experimental and observational studies are insufficient to address these problems. Furthermore, the static nature of traditional, model-based human reliability analyses (HRAs) are not able to handle the dynamic environmental elements that can impact human performance. To address this issue and allow analysts to accurately predict medication error rates, we develop a new HRA called the Systems Analysis for Formal Pharmaceutical Human Reliability (SAFPHR). This method addresses the limits of previous HRAs by combining concepts from the Cognitive Reliability and Error Analysis Method (CREAM) HRA with probabilistic model checking, a computational tool for automatically proving properties about complex, stochastic systems. In this paper, we use SAFPHR to analyze a common community pharmacy dispensing procedure, compare our results to published error rates, and use our results to explore interventions that could reduce error rates. We ultimately discuss our results and explore how our method could be developed in future research.