Artigos

INTRODUCTION
Healthcare systems face escalating challenges, including rising demand, new technologies, and financial constraints1,2. Mintzberg3 explains why healthcare system must be reframed to ensure its sustainability. The ability of healthcare systems to adapt and respond effectively to various challenges and demands is its resilience, which involves the capacity to maintain the quality of care and services, even in the face of disruptive events such as epidemics, disasters, or increased demand. It also encompasses the ability to anticipate, monitor, respond, and learn from these events, ensuring that the system can continue to function effectively4. Massuda et al5 emphasize the importance of enhancing health system resilience to counteract external and internal shocks.
Health systems should be considered an intrinsic component of their daily operations, rather than solely an emergency contingency. Experience has demonstrated that, in addition to emergency readiness, health systems must maintain consistent and efficient performance in their routine functions. Consequently, resilience should be viewed as an inherent and ongoing characteristic of daily operations, indispensable for ensuring the robustness and sustainability of the Unified Health System (SUS) and other systems4.
The World Health Organization acknowledges patient safety as priority. The achievement of patient safety goals, is guided by the values of patient and family’s engagement, collaboration, data-driven approach, actionable improvements, context-specific solutions, combined expertise, and the fostering of a safety culture6. Among its strategic objectives is “build high-reliability health systems and health organizations that protect patients daily from harm”7.
Jeffcott, Ibrahim and Cameron8 emphasize how resilience can benefit patient safety efforts by shifting the focus from a traditional, reactive approach to errors to a proactive focus on error recovery. Smith and Plunkett9 say that resilience promotes safety by enabling systems to succeed under both expected and unexpected conditions, fostering psychological safety and the development of a safety culture.
Analyzes on Patient Safety indicate 10% of patients experienced adverse events during care, with 60% of these considered preventable. Brazilian scenario on notifications on healthcare incidents highlight major challenges10.
Adverse events (AE) are unforeseen occurrences that cause harm to the patient during care. According to the National Health Surveillance Agency (ANVISA) AE in Brazil are increasing. Hospital environments are the most representative, with the highest frequency in Failures during healthcare, a category that includes medication-related errors11,12,13. Medication-related errors are a serious concern often going unreported14.
Many studies were conducted to improve understanding of AE, identify critical areas, and propose improvements in patient safety15,16,17. Among the approaches employed are the Plan, Do, Check, Act cycle (PDCA)22 and Problem Structuring Method (PSM)22. The use of PSM can be an alternative for traditional approaches, using systemic tools to take into consideration the complexities involved in the problem which may contribute to a better understanding of the internal problems dynamics. Clarifying the intricacies helps in the search for sustainable alternatives that strengthen resilience at work in healthcare institutions.
This study aims to contribute to the enhancement of healthcare system resilience by addressing the critical challenge of Adverse Events related to medication errors. By employing a Soft Systems Methodology (SSM)22 in at the emergency department of a teaching hospital, the authors explored medication errors and propose systemic improvements. The work pursues to bolster healthcare resilience. Ultimately, this study will contribute to improved patient safety.
LITERATURE REVIEW
Healthcare systems resilience
The resilience of health systems can be understood as their ability to offer quality services to the population, both in structural and financial terms. This highlights the importance of the functions necessary for health systems to respond and adapt. A systematic literature review conducted by Debbie et al18 identified as key characteristics of a strong health systems: context-based redistribution of workers, task-shifting policy, results-based financing policy, high political commitment, community-based response planning, multi-sectoral collaboration, advanced infrastructures, adequate number of workers, and, integrated and multi-sectoral approaches based on the principles of primary health care. Sari et al19 identified seven key domains for resilient hospitals: readiness to face digital transformation, effective leadership, flexibility in managing resources, situation awareness and resilience ethos, implementation of marketing management, networking, and disaster anticipation. The authors emphasize the need for hospitals to adapt to disruptions caused by technological, economic, and societal changes, as well as policy changes and political crises.
The growing importance of the resilience of health systems stands out, highlighting their effectiveness in providing health services to the population by creating a solid foundation to face future challenges on a global scale20. This approach not only improves the ability to respond to immediate crises, but also promotes sustainable development and long-term prosperity.
Related to methodologies to foster healthcare systems resilience21, identified that authors assessed the resilience of health services delivery in a variety of ways: qualitative studies, semi-structured interviews with decision makers and document analysis, analysis and observation and focus group discussions, they observed that only two of the studies applied a specific framework of health system resilience.
Problem Structuring Methods (PSM) and Adverse events (AE)
Problem Structuring Methods (PSMs) are a collection of tools designed to help groups tackle complex issues. Unlike traditional methods PSMs prioritize defining the problem itself. These methods are interactive and participatory, encouraging collaboration among stakeholders with diverse perspectives22. The most common PSMs are Soft Systems Methodology (SSM), Strategic Choice Approach (SCA) and Strategic Options Development and Analysis (SODA).
SSM focuses on the understanding of the problem, using imagens (rich picture) and the CATWOE analysis (Customers, Actors, Transformation, Weltanschauung, Owner, Environment). SCA is more prescriptive, with defined stages for strategic decision-making, emphasizing long-term consequences of choices23. SODA is tailored towards evaluating and comparing pre-defined strategic options24. In the problematic situation presented in this study SSM was the suitable method to fulfil the aim of understanding and exploring the complex issue of medication-related errors.
A literature review, done on August 2024, on Socpus, Web of Science and Pubmed, for (“problem structuring” or “PSM”) and (“adverse event*” or “AE”), on topics, no other filters, returned hundreds of documents, but no one related to problem structuring methods such as SSM. Repeating the search changing only the descriptors for "resilience" and ("problem structuring method*" or "PSM") and ("healthcare" OR "health care" or "health service*"), returned a total of 18 documents (not excluding duplicates) and, once more, none related to the specific topics of this research.
Gomes Júnior and Schramm25 mention that PSM, mostly SSM, has been applied in healthcare to improve services, support the formulation of public health policies, and address other issues related to its management. Augustsson, Churruca and Braithwaite26 conclude that SSM has the potential to facilitate change in healthcare complex settings. Lamé, Jouini and Stal-Le Cardinal27 combined SSM and discrete-event simulation to address issues related to waiting times and process inefficiencies in the chemotherapy unit. Crowe et al28 used SSM and a quantitative method to improve integration and continuity of care across sectors within resource constraints, specifically involving infants with congenital heart disease (CHD) whose care pathway spans multiple sectors. A consensus among those authors is that SSM is a powerful approach, helping decision makers manage conflicting views and aligning stakeholders.
Brazilian National Healthcare System
The Brazilian public healthcare network is known as the “Unified Health System” or SUS (Sistema Único de Saúde). It is a free service offered to all permanent citizens and foreigners in Brazilian territory (including undocumented individuals) and it is organized into health regions, considering the socioeconomic, epidemiological, and healthcare organization characteristics of each location. Each region has a network of interconnected health services, from primary care to specialized care. This regionalized organization aims to guarantee equity in access to healthcare, focusing on the population and its specific needs29. The management of public hospitals follows the principles of legality, impersonality, publicity, and others30.
Within the context of healthcare, Zurynski et al2 explore the challenges related to: a) lack of coordination of health systems and integration across clinical disciplines and healthcare sectors, b) limited investment in building workforce capacity and stakeholder involvement and c) its fragmented nature, including power imbalances among health professions and resistance to changes in the scope of practice. To Pimentel29, SUS challenges for 2023 are: a) inadequate funding, which can lead to shortages of medical supplies and staff, as well as long wait times for care; b) disparities in the quality and availability of healthcare services across different regions; c) impact of the Covid-19 pandemic, that accelerated the deterioration of the healthcare system and increased health inequalities.
These challenges imply the need to boost resilience and the Brazilian healthcare network faces similar difficulties.
Medication process along a hospital emergency department
According to the Regional Nursing Council31, there is a medication system, that is, a set of steps that include identification and prescription, including dispensing, administration and monitoring of the expected effects when administering the prescribed drug. It is a multi-professional activity, which involves diverse knowledge and has a complexity that needs to be discussed comprehensively. This system contemplates the following steps:
? Purchasing process: understanding the demand, finding, or inviting suppliers, quote prices and select the best cost-benefit supplier. The most common processes are bidding or auction.
? Distribution process: transporting the supplies along the supply chain until it reaches their destination at the hospital warehouse.
? Prescription process: choosing the medication for each clinical situation, considering the individual's organic factors and factors related to the drug. It`s recommended to know the properties of medications, risk situations and care with high-risk drugs;
? Dispensation process: distribution of the medicine by the pharmacy to the requesting units;
? Handling process: receiving and handling medicines to be administered. The preparation can be done in the hospital's pharmacy department, depending on the institution's standardized routine. Or by the nursing teams in the sectors that receive the dispensed medicines and supplies;
? Administration process: administering medications to the patient, as prescribed.
? The above description on the medication process considers only the care process.
The acquisition process represents the steps prior to the arrival of the medication to the patient. The process of acquisition, management and control of medicines prescribed follows a decentralized model of pharmaceutical services management. The above description on the medication process considers only the care process. The acquisition process represents the steps prior to the arrival of the medication to the patient. The process of acquisition, management and control of medicines prescribed follows a decentralized model of pharmaceutical services management.
Safe medication management is vital to ensuring the quality and safety of healthcare. However, the complexity of healthcare and the processes involved, along with the pressures of the hospital environment, can increase the risk of errors and AE related to medications.

METHOD
This study followed an action research approach, that allows the development and exposure of a problematic, encompassing the analysis and execution of concrete improvements to the investigation32. The investigative context was developed in the emergency department of a public teaching hospital, located in the city of Rio de Janeiro, Brazil. The authors utilized SQUIRE guideline for this study33.
The action research followed the 3-phase SSM34, as presented in in Figure 1. The steps interact with each other systemically and are explained in detail
Figure 1: Visual overview of a configuration of SSM in three phases (Re-SSM). Adapted from Georgiou (2015).
Source: Francozo, Paucar-caceres and Belderrain (2021).
Step 1: Understanding the Problem Situation
In this phase, contextual knowledge about the problematic situation was recorded, including:
a) identifying the agents involved;
b) describing the contextual immersion and cultural influences within the situation (socio-cultural dynamics), and
c) describing the power or influence enjoyed by each agent (agents’ power to act).
The results are expressed visually in an image, the Rich Picture, capturing the connections and views of each stakeholder.
Step 2: Identify Necessary Changes
This phase focuses on identifying the essential changes required to transform the undesirable state of the situation into a desirable one. Four rules are stipulated regarding the proposed transformations. They must be attainable, pertinent, empowered by every agent and align with organizational goals and culture. Four stakeholders, chosen by their impact in decision making, availability and knowledge, were interviewed, with non-structured questions:
• In an emergency department where medication prescriptions are manual, with no administrative staff to properly organize medications, what do you think are the factors that predispose to adverse events with the administration of medications?
• What factors do you understand contribute to these events, and why?
• And, what alternatives do you suggest solving it?
Step 3: Designing Models for Operationalizing Changes
The purpose of phase 3 is to design systemic plans for addressing complex and uncertain situations. It involves contextualizing the identified transformations using the CATWOE approach, designing models for operationalizing these transformations, and formulating a systemic intervention based on the designed models – the Human Activity Systems (HAS). A HAS can be conceptualized as a framework wherein individuals engage in specific activities to fulfil a particular purpose. In the context of CATWOE analysis, a HAS is constructed for each identified transformation. Subsequently, a supersystem is developed to comprehensive map and capture the entirety of these activities, while also monitoring specific indicators.
RESULTS AND DISCUSSION
Soft System Methodology Application
The evaluation of internal reports from AE revealed medicine-related errors were a major concern in the emergency department of the teaching hospital. Once its causes and solutions are complex and uncertain the team started the 3-step SSM application.
Step 1: Understanding the Problem Situation
Context of the Problematic Situation
Located in an area with public safety concerns, this teaching hospital tackles complex healthcare procedures. The hospital excels in teaching, research, and advanced treatments. Its emergency department focuses on post-procedure complications and doesn't accept walk-in patients. Additionally, the Brazilian regulatory system, which governs access to healthcare resources at all levels (federal, regional, and municipal), can also direct patients to the hospital.
This federally managed university hospital faces several challenges, including poor infrastructure and a lack of staff. Deterioration of infrastructure due to lack of maintenance; lack of human resources leading to a disarticulation, due to the non-replacement, precariousness, and non-substitution of professionals; and inadequate control of materials and are issues described by its professionals.
Material and medication purchases are determined by the previous three years' consumption history. Local hospital managers have the flexibility to assess and adjust their needs as required. They then communicate these adjustments to the central purchasing department. This department oversees procurement for the entire university hospital network, including the teaching hospital, affiliated institutions within the university (such as maternity and pediatric hospitals), and other federal healthcare facilities in Rio de Janeiro. By centralizing purchasing, the network aims to achieve the best cost-effectiveness for public funds.
Medications are received at the hospital's materials warehouse and then distributed to the central pharmacy. The central pharmacy supplies medications to unit-based pharmacies located on each floor. Requests are currently made through handwritten, multi-copy prescriptions delivered by hand. After receiving medication and verifying the prescription, nurses prepare and administer it. If dosages or concentrations differ from what's prescribed, nurses leverage their expertise to adapt the available medication to the doctor's orders. In case of medication shortages, the team can request assistance from their internal (and external if needed) network for borrowing or seek alternative treatment options with the doctor and pharmacist.
The hospital fills its positions through public competitions or outsourcing contracts. A significant portion of outsourced personnel are directly involved in patient care. As a teaching hospital, the institution has a large student body with assigned tutors, but the educational support is understood to be insufficient. Students lack onboarding. Limited educational support for interns, residents, and on-duty staff, coupled with the absence of consistent tutoring and computerized systems, increases the risk of mistakes in prescribing medications (wording, standardization, dose, route, timing, and indication).
All levels of nursing students undergo an onboarding process. Despite of it, the limited number of nursing students can't alleviate the strain on the understaffed care team. The combination of overcrowding, high patient demand, noise, and structural problems creates a frustrating work environment that fuels job dissatisfaction. Compounding these issues further are staff shortages, compromised sleep schedules due to inadequate rest areas and the lack of air conditioning.
a) Identifying the agents involved: by reviewing the medication-errors AE reports and action plans, along with firsthand observation, key stakeholders were identified: physicians, nurses, nursing technicians, departmental leaders, quality and patient safety manager, nutritionist, patient transport aides and buyer.
b) Describing the socio-cultural dynamics: Purchases are made jointly for all instruments of the federal health network; the workforce is mostly outsourced, poor working conditions lead to high turnover of professionals as well as the lack of motivation of those who remain, the region suffers from problems related to public safety; there is no computerized system to carry out activities related to requesting and administering medication. There is little engagement of local management with the purchasing processes in terms of reviewing and criticizing demand, even less with making projections. The pharmacy team serves the whole institution and has a small team to meet the demand of all hospital wards;
c) Describing the agents’ power to act: physicians (prescribe and discuss necessary changes based on a patient's condition), nurses (prepare and administer medications, organize patient care, discuss changes and obtain alternative medications when needed), nursing technicians (assist nurses), pharmacists (manage medication distribution), departmental leaders (order medication purchase), quality and patient safety manager (report and facilitate investigation of AE), nutritionist (evaluate patient nutrition and participate in decision-making regarding medications and care), patient transport aides (transport patients and supplies) and buyer (purchase materials and medication).
During non-structured individual interviews, stakeholders described their experiences and explored them in the context of medication-related errors. The resultant Rich Picture is presented on Figure 2.

the purchasing process of medications and supplies. They distribute these items to the peripheral pharmacy or nursing station based on type. Following a doctor's consultation, a manual prescription is sent to the appropriate location for dispensing. Due to potential illegibility, nurses may need to interpret the prescription before administering medications. The pharmacy handles specialized medications like antibiotics, while the nursing station provides most others. Any AE experienced by the patient after drug administration are reported by nurses to a regulatory body, which monitors these events and provides recommendations to improve patient safety. There is high staff turnover due to various factors.
Step 2: Identify Necessary Changes
Based on the interview results and the overview provided by the Rich Figure, a second row of interviews with the same stakeholders were conducted, and they answered what they thought to be the most needed aspects for change and, they were asked to explore potential alternative solutions to be addressed. Table 1 displays the transformations, while Table 2 outlines the CATWOE framework corresponding to each transformation.

Table 1: Transformations needed identified by stakeholders.
Input Output

T1 No computerized system to carry out activities related to requesting and administering medication, making the process time-consuming and more susceptible to errors. ? Prescriptions are legible, ensuring a smooth management process that minimizes wasted time and reduces the probability of errors.
T2 Workforce is mostly outsourced, poor working conditions lead to high turnover of professionals. ? Healthy turnover among care professionals.
T3 Staff turnover linked to fatigue and employee well-being. ? Healthy turnover related to staff well-being.
T4 Purchases are made jointly for all instruments of the federal health network, seeking general standardization that may not meet the specific demand of the teaching hospital. ? Medicine procurement process tailored to meet local demand.
T5 Staff turnover restricting the accumulation of knowledge and expertise. ? Sufficient professional experience and expertise to meet the demand of the emergency department.
T6 High patient load leading to increased workload and time pressure. ? Balanced demand and resources relation on emergency department.
Source: The authors (2023).

Although all transformations adhere to the established rules, the implementation of T2 and T6 poses distinctive challenges. T2 requires engaging stakeholders not previously involved, particularly those related to workforce hiring. T6, given its requirement for a systemic comprehension of demand and the necessity for a distinct SSM approach, will not be further elaborated in this study.
Step 3: Designing Models for Operationalizing Changes
The CATWOE and Human Activity Systems (HAS) developed are presented in Table 2 and Figure 3.

Source: The authors (2023).
The supersystem boxes outline potential actions for improving the overall system. These actions emphasize that organizing the work environment and standardizing routines are crucial first steps for any other improvement efforts.
It is also important to highlight that the activities planned for these transformations contribute to the resilience of the system by increasing efficiency, improving communication, reducing turnover and strengthening the ability to respond and adapt to changes and challenges. A more resilient health system can maintain continuity of care and quality of services, even in the face of difficulties, ensuring better results for patients and for the organization.
The authors recognize some limitations in the extent of this study. It’s about the reality of the specific teaching hospital, there is a limitation of resources to implement the transformations proposed and limited access to people who belong to the purchasing process outside of the hospital walls.
CONCLUSION
This study aimed to strengthen healthcare system resilience by addressing the critical challenge of AE related to medication errors, employing the Soft Systems Methodology (SSM) in the emergency department of a teaching hospital.
The systemic approach allowed the team to better understand different nuances of the problem, best defining it within its complexity. The root causes stemmed not only from care delivery but also from issues integrating and executing the entire medication process, from administrative tasks like purchasing to the clinical aspects of medication management. Although simple in nature, the actions of organizing the work environment and standardizing the routines are the foundations for every other action.
The SSM framework, by emphasizing a collaborative approach and seeking integrated solutions, proves itself to be key in achieving system resilience. This focus on integrating people into the process demonstrably enhances the system's ability to withstand challenges.
Future studies would analyse the effectiveness of the solutions proposed and the difficulties associated to complete them in such a complex environment. Also, research on comparative studies with other hospitals that have faced similar challenges to identify the practices carried out and compare them for the purpose of reproducing the best model that suits that environment36.

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