Date of Award

August 2020

Document Type


Degree Name

Master of Science (MS)


Industrial Engineering

Committee Member

David M Neyens

Committee Member

Kapil C Madathil

Committee Member

Mary E Kurz


Medication errors in anesthesia are prevalent and efforts to address medication errors bring with them new potential avenues of failure, especially when the work system and ‘work as done’ are not considered in the design of the intervention. I employed two methodologies in interviews of anesthesia providers to help further understand the context of anesthesia ‘work as done’ to inform the design of future medication error-reducing interventions. Results of the first interview methodology, the critical decision method, revealed a diverse array of challenging scenarios in which ‘work as done’ often deviates from ‘work as imagined.’ Results of the second interview methodology, vignette-based interviews, revealed how the decision-making processes of anesthesia providers may vary even when managing an identical case. These interviews provide context to the otherwise nebulous ‘variability’ of anesthesia provider ‘work as done.’ This context highlights the potential unforeseen dangers that may occur with the addition of future interventions and suggests avenues in which future interventions may fit better into the workflow of the anesthesia provider with design considerations. Future design efforts should focus on supporting the resilience of anesthesia providers: the information seeking and problem anticipation which are used to safely manage the uncertainty and complexity of their work. Future work should assess how ‘work as done’ may vary in different hospitals, and additionally focus on how ‘work as done’ influences the process of medication administration.



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