{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T14:51:36Z","timestamp":1774882296230,"version":"3.50.1"},"reference-count":31,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T00:00:00Z","timestamp":1774828800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Vet. Sci."],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Medication error is a major cause of preventable harm in healthcare. Superficially, solutions to medication error appear simple, however medication administration often occurs during high-risk clinical scenarios, and under varied and challenging conditions which reduce intervention efficacy. Administering medication by infusion (AMI) is particularly complex. To develop feasible, effective and sustainable medication safety, requires an in-depth understanding of clinical conditions. Resilience engineering techniques can insight into process performance and variation and can identify how frontline staff can be better supported.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A Functional Resonance Analysis Method (FRAM) based process evaluation was conducted in a multidisciplinary small-animal referral hospital. Information on work-as-imagined was obtained from institutional standard operating procedures (SOPs). Work-as-done was explored using an anonymous online staff survey with open-ended questions investigating process variation. Data were analysed using the four FRAM phases: identifying process functions, characterising performance variability, assessing functional resonance, and generating resilience-informed recommendations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Result<\/jats:title>\n                    <jats:p>There were 45 responses to the survey included in analysis. The SOPs described a relatively linear process consisting of 7 phases whereas the FRAM model consisted of 45 interrelated and interdependent functions. Substantial discrepancies were identified between work-as-imagined and work-as-done. Performance variability and context dependent workarounds were common, particularly in relation to communication, dose calculators, infusion sheets, and double-checking, which were often impracticable under conditions of high workload, limited staffing, or clinical urgency. Interventions aimed at improving frontline abilities to anticipate, monitor and adjust to challenging conditions, and allowing the organisation to learn from outcomes were developed from the model.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>FRAM demonstrated that AMI is a highly complex and variable process which is not adequately captured by existing SOPs. Performance variability reflected necessary adaptations to local conditions rather than individual non-compliance. Resilience-informed redesign of AMI processes may better support frontline staff and improve medication safety across diverse veterinary clinical contexts.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fvets.2026.1781437","type":"journal-article","created":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T13:59:57Z","timestamp":1774879197000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Using Functional Resonance Analysis Methodology to identify potential safety improvements in the process of administering medications by infusion in a veterinary hospital"],"prefix":"10.3389","volume":"13","author":[{"given":"Matthew","family":"McMillan","sequence":"first","affiliation":[{"name":"Faculty of Veterinary Science, LMU Small Animal Clinic, Ludwig-Maximilians University of Munich","place":["Munich, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,3,30]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"l4185","DOI":"10.1136\/bmj.l4185","article-title":"Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis","volume":"366","author":"Panagioti","year":"2019","journal-title":"BMJ"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"313","DOI":"10.1186\/s12916-020-01774-9","article-title":"Preventable medication harm across health care settings: a systematic review and meta-analysis","volume":"18","author":"Hodkinson","year":"2020","journal-title":"BMC Med"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"12","DOI":"10.3389\/fvets.2019.00012","article-title":"Medical errors cause harm in veterinary hospitals","volume":"6","author":"Wallis","year":"2019","journal-title":"Front Vet Sci"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"e1629","DOI":"10.1002\/vetr.1629","article-title":"Type and impact of clinical incidents identified by a voluntary reporting system covering 130 small animal practices in mainland Europe","volume":"191","author":"Schortz","year":"2022","journal-title":"Vet Rec"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"418","DOI":"10.1093\/intqhc\/mzv063","article-title":"Resilient health care: turning patient safety on its head","volume":"27","author":"Braithwaite","year":"2015","journal-title":"Int J Qual Health Care"},{"key":"ref6","volume-title":"FRAM: The Functional Resonance Analysis Method: Modelling Complex Socio-Technical Systems","author":"Hollnagel","year":"2017"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"143","DOI":"10.1007\/s10111-010-0147-2","article-title":"The ETTO principle and organisational strategies: a field study of ICU bed and staff management","volume":"12","author":"Xiao","year":"2010","journal-title":"Cogn Technol Work"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"199","DOI":"10.1136\/bmjqs-2017-006917","article-title":"Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care","volume":"27","author":"Grant","year":"2018","journal-title":"BMJ Qual Saf"},{"key":"ref9","doi-asserted-by":"crossref","DOI":"10.1201\/9781315616247","volume-title":"The ETTO Principle: Efficiency-Thoroughness Trade-off: Why Things that Go Right Sometimes Go Wrong","author":"Hollnagel","year":"2017"},{"key":"ref10","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2025-019063","article-title":"Do patient safety incident investigations align with systems thinking? An analysis of contributing factors and recommendations","author":"Bowditch","year":"2025","journal-title":"BMJ Qual Saf"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"104827","DOI":"10.1016\/j.ssci.2020.104827","article-title":"Framing the FRAM: a literature review on the functional resonance analysis method","volume":"129","author":"Patriarca","year":"2020","journal-title":"Saf Sci"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"1074","DOI":"10.11124\/JBIES-21-00099","article-title":"The functional resonance analysis method as a health care research methodology: a scoping review","volume":"20","author":"McGill","year":"2022","journal-title":"JBI Evid Synth"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"e002023","DOI":"10.1136\/bmjoq-2022-002023","article-title":"Implementation of barcode medication administration (BMCA) technology on infusion pumps in the operating rooms","volume":"12","author":"Hogerwaard","year":"2023","journal-title":"BMJ Open Qual"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"mzaf074","DOI":"10.1093\/intqhc\/mzaf074","article-title":"Using FRAM visualisations in quality improvement projects: identifying and testing strategies to improve anticoagulant use in the perioperative process","volume":"37","author":"Luijcks","year":"2025","journal-title":"Int J Qual Health Care"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1097\/PTS.0000000000000515","article-title":"Preoperative anticoagulation management in everyday clinical practice: an international comparative analysis of work-as-done using the functional resonance analysis method","volume":"17","author":"Damen","year":"2021","journal-title":"J Patient Saf"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"103113","DOI":"10.1016\/j.apergo.2020.103113","article-title":"Using FRAM to explore sources of performance variability in intravenous infusion administration in ICU: a non-normative approach to systems contradictions","volume":"86","author":"Furniss","year":"2020","journal-title":"Appl Ergon"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"177","DOI":"10.1016\/j.ssci.2019.08.023","article-title":"Gatekeeper family doctors operating a decentralized referral prioritization system: uncovering improvements in system resilience through a grounded-based approach","volume":"121","author":"Arcuri","year":"2020","journal-title":"Saf Sci"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.ress.2018.04.023","article-title":"Application of a non-linear model to understand healthcare processes: using the functional resonance analysis method on a case study of the early detection of sepsis","volume":"177","author":"Raben","year":"2018","journal-title":"Reliab Eng Syst Saf"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"213","DOI":"10.1186\/s12916-018-1212-6","article-title":"Guideline developers are not the only experts: utilising the FRAM method in sepsis pathways","volume":"16","author":"Roland","year":"2018","journal-title":"BMC Med"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"174","DOI":"10.1186\/s12916-018-1164-x","article-title":"Participatory design of an improvement intervention for the primary care management of possible sepsis using the functional resonance analysis method","volume":"16","author":"McNab","year":"2018","journal-title":"BMC Med"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"9495","DOI":"10.3390\/app14209495","article-title":"The functional resonance analysis method (FRAM) application in the healthcare sector: lessons learned from two case studies on medical device management","volume":"14","author":"Fargnoli","year":"2024","journal-title":"Appl Sci"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"851","DOI":"10.1186\/s12913-023-09832-7","article-title":"Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the functional resonance analysis method","volume":"23","author":"Hedqvist","year":"2023","journal-title":"BMC Health Serv Res"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"103060","DOI":"10.1016\/j.apergo.2020.103060","article-title":"\u2018Handing over to the patient\u2019: a FRAM analysis of transitional care combining multiple stakeholder perspectives","volume":"85","author":"O\u2019Hara","year":"2020","journal-title":"Appl Ergon"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"365","DOI":"10.1186\/1472-6963-14-365","article-title":"Hospital discharge of the elderly-an observational case study of functions, variability and performance-shaping factors","volume":"14","author":"Laugaland","year":"2014","journal-title":"BMC Health Serv Res"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"e412","DOI":"10.3399\/BJGP.2024.0284","article-title":"Safety issues in post-discharge care of older patients in general practice: an ethnographic study","volume":"75","author":"Spencer","year":"2025","journal-title":"Br J Gen Pract"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"191","DOI":"10.1186\/s12913-022-07537-x","article-title":"Implementing structured follow-up of neonatal and paediatric patients: an evaluation of three university hospital case studies using the functional resonance analysis method","volume":"22","author":"Bos","year":"2022","journal-title":"BMC Health Serv Res"},{"key":"ref27","first-page":"153","volume-title":"Human Factors: A System View of Human, Technology and Organisation","author":"Alm","year":"2010"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"853","DOI":"10.1016\/j.ssci.2019.06.026","article-title":"Double checking injectable medication administration: does the protocol fit clinical practice?","volume":"118","author":"Schutijser","year":"2019","journal-title":"Saf Sci"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"106970","DOI":"10.1016\/j.ress.2020.106970","article-title":"Semi-quantitative application to the functional resonance analysis method for supporting safety management in a complex health-care process","volume":"202","author":"Kaya","year":"2020","journal-title":"Reliab Eng Syst Saf"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1186\/s13012-015-0317-y","article-title":"Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines","volume":"10","author":"Clay-Williams","year":"2015","journal-title":"Implement Sci"},{"key":"ref31","volume-title":"Safety-I and Safety-II: The Past and Future of Safety Management","author":"Hollnagel","year":"2014"}],"container-title":["Frontiers in Veterinary Science"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fvets.2026.1781437\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T13:59:58Z","timestamp":1774879198000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fvets.2026.1781437\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,30]]},"references-count":31,"alternative-id":["10.3389\/fvets.2026.1781437"],"URL":"https:\/\/doi.org\/10.3389\/fvets.2026.1781437","relation":{},"ISSN":["2297-1769"],"issn-type":[{"value":"2297-1769","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,30]]},"article-number":"1781437"}}