The purpose of this assignment is to assess how quality improvement can be used to reduce errors and improve patient safety.
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.
Write a word chapter for a training manual, including graphics, that illustrates the following aspects as they relate to SEIPS:
Describe the seven types of errors that can occur in a health care environment and provide examples of each. Explain the impact that errors have on an organization. Describe measures that could have been implemented to improve patient safety and reduce the occurrence of each error you described.
Discuss the framework of the SEIPS tool and how it is used within a health care environment. Compare the SEIPS tool with one other error-reduction strategy presented in the textbook and explain when each tool might be applied.
Explain the positive effect that the SEIPS tool can have on the reduction of errors in high-risk health care settings.
Discuss the relationship between CQI and SEIPS in producing quality outcomes for health care organizations. How does improving quality outcomes with a patient-centric focus align with Christian worldview principles?
Full Answer Section
Decision errors: These errors occur when a healthcare provider makes a wrong decision. Examples include:
A physician deciding to discharge a patient too early
A nurse deciding not to give a patient a medication because they are worried about side effects
Perceptual errors: These errors occur when a healthcare provider fails to see or hear something correctly. Examples include:
A nurse failing to see a rash on a patient's skin
A physician failing to hear a patient's complaints of chest pain
Communication errors: These errors occur when there is a breakdown in communication between healthcare providers or between healthcare providers and patients. Examples include:
A nurse failing to communicate a change in a patient's condition to the physician
A physician failing to explain a patient's treatment plan to them in a way that they can understand
System errors: These errors are caused by problems with the healthcare system itself. Examples include:
A medication error due to a poorly designed medication dispensing system
A patient fall due to inadequate staffing levels
Impact of Errors on an Organization
Medical errors can have a devastating impact on patients, their families, and healthcare organizations. Patients may experience serious injury or death, and their families may suffer emotional and financial hardship. Healthcare organizations may face lawsuits, financial penalties, and damage to their reputation.
Measures to Improve Patient Safety
There are a number of measures that healthcare organizations can implement to improve patient safety and reduce the occurrence of errors. These include:
Standardizing processes and procedures: This helps to ensure that tasks are performed consistently and correctly.
Using technology to support healthcare providers: For example, computerized physician order entry (CPOE) systems can help to reduce medication errors.
Creating a culture of safety: This means encouraging healthcare providers to report errors and to learn from them.
Empowering patients and their families to be involved in their care: This can help to identify potential errors and to ensure that patients are receiving the care they need.
SEIPS Framework
The SEIPS framework is a quality improvement tool that can be used to reduce errors and improve patient safety. It is a systematic approach to identifying and addressing the root causes of errors.
The SEIPS framework includes the following steps:
Identify the problem: The first step is to identify the specific error or safety problem that is being addressed.
Analyze the problem: Once the problem has been identified, the next step is to analyze it to identify the root causes. This can be done using a variety of methods, such as root cause analysis (RCA) or failure mode and effects analysis (FMEA).
Develop solutions: Once the root causes of the problem have been identified, the next step is to develop and implement solutions.
Monitor and evaluate the solutions: The final step is to monitor and evaluate the solutions to ensure that they are effective in reducing errors and improving safety.
Comparison of SEIPS with Other Error-Reduction Strategies
There are a number of other error-reduction strategies that are used in healthcare. One common strategy is to use checklists. Checklists can be helpful for ensuring that tasks are performed completely and correctly. However, checklists are not always effective in preventing errors.
Another common error-reduction strategy is to use training. Training can help healthcare providers to develop the skills and knowledge they need to perform their jobs safely. However, training is not always effective in preventing errors, especially if the root cause of the error is a system error.
The SEIPS framework is a comprehensive approach to error reduction that can be used to address both latent and active errors. Latent errors are system errors that create the conditions for errors to occur. Active errors are the specific errors that are made by healthcare providers. By addressing both latent and active errors, the SEIPS framework can help to reduce errors and improve patient safety.
Sample Answer
Chapter 1: Reducing Errors and Improving Patient Safety with SEIPS
Seven Types of Errors in a Health Care Environment
-
Skill-based errors: These errors occur when a healthcare provider does not have the skills or knowledge necessary to perform a task correctly. Examples include:
- A nurse accidentally giving the wrong medication to a patient
- A surgeon making an incision in the wrong place
-
Rule-based errors: These errors occur when a healthcare provider applies a rule incorrectly. Examples include:
- A nurse failing to check a patient's allergies before administering a medication
- A pharmacist dispensing the wrong dosage of a medication
-
Knowledge-based errors: These errors occur when a healthcare provider lacks the knowledge necessary to make a correct decision. Examples include:
- A physician misdiagnosing a disease
- A nurse failing to recognize the signs and symptoms of a patient's condition