Systems Engineering Initiative for Patient Safety (SEIPS)

Sample Solution

Human error is a concern that affects every aspect of health care, and is something that providers must account for when creating systems and processes to ensure patient safety. The Systems Engineering Initiative for Patient Safety (SEIPS) was created as a quality improvement tool to better understand the elements that threaten safety and to recommend ways organizations can improve quality outcomes by reducing risk.

This chapter will discuss the following aspects of SEIPS as they relate to quality improvement in health care:

• Seven types of errors that can occur in a health care environment
• The impact of errors on an organization
• Measures that could have been implemented to improve patient safety and reduce the occurrence of each error
• The framework of the SEIPS tool and how it is used within a health care environment
• A comparison of SEIPS with one other error-reduction strategy
• The positive effect that SEIPS can have on the reduction of errors in high-risk health care settings
• The relationship between continuous quality improvement (CQI) and SEIPS in producing quality outcomes for health care organizations
• How improving quality outcomes with a patient-centric focus aligns with Christian worldview principles

Seven Types of Errors in Health Care

The seven types of errors that can occur in a health care environment are:

1. Medication errors
2. Diagnostic errors
3. Laboratory errors
4. Surgical errors
5. Infection control errors
6. Communication errors
7. System errors

Medication errors are the most common type of medical error, accounting for approximately 44,000 deaths each year in the United States. Examples of medication errors include:

• Giving the wrong medication to the wrong patient
• Giving the wrong dose of medication
• Giving medication at the wrong time
• Failing to give medication that has been ordered
• Administering medication by the wrong route

Diagnostic errors are the second most common type of medical error. Examples of diagnostic errors include:

• Failing to diagnose a condition
• Misdiagnosing a condition
• Delaying diagnosis
• Ordering the wrong tests or procedures

Laboratory errors can occur in any phase of the laboratory process, from specimen collection to reporting of results. Examples of laboratory errors include:

• Mislabeling specimens
• Losing specimens
• Performing the wrong tests
• Reporting incorrect results

Surgical errors can occur before, during, or after surgery. Examples of surgical errors include:

• Operating on the wrong body part
• Leaving surgical instruments or sponges inside the patient
• Performing the wrong surgery
• Failing to take proper precautions to prevent infection

Infection control errors can occur when healthcare workers fail to follow proper infection control procedures. Examples of infection control errors include:

• Failing to wash hands properly
• Not wearing appropriate personal protective equipment (PPE)
• Not cleaning and disinfecting equipment properly

Communication errors can occur between healthcare workers, between healthcare workers and patients, and between healthcare workers and patients' families. Examples of communication errors include:

• Failing to pass on important information about a patient's condition or care
• Giving conflicting instructions to patients
• Misunderstanding a patient's instructions or concerns

System errors are errors that occur in the systems and processes that support healthcare delivery. Examples of system errors include:

• Faulty equipment
• Poorly designed or confusing forms or checklists
• Lack of training on new equipment or procedures

Impact of Errors on an Organization

Medical errors have a significant impact on both patients and organizations. When patients are harmed by medical errors, they may experience physical injury, emotional distress, and financial hardship. Organizations that experience medical errors may face lawsuits, financial losses, and reputational damage.

In addition to the human cost, medical errors also have a significant economic impact. The estimated annual cost of medical errors in the United States is $17-$29 billion.

Measures to Improve Patient Safety and Reduce Errors

There are a number of measures that healthcare organizations can implement to improve patient safety and reduce the occurrence of errors. Some examples include:

• Medication errors:
  • Use computerized physician order entry (CPOE) systems
  • Use barcode scanning technology to verify medications
  • Implement medication reconciliation programs
• Diagnostic errors:
  • Use clinical decision support systems
  • Implement second opinion programs
  • Encourage teamwork and collaboration among healthcare workers
• Laboratory errors:
  • Use barcode scanning technology to track specimens
  • Implement quality control measures
  • Provide training on laboratory procedures