Systems Engineering Initiative for Patient Safety

System Engineering Initiative for Patient Safety In healthcare medical errors are the third leading cause of death and are defined as the failure of a planned action to be accomplished or the wrong plan implemented (Johnson & Sollecito, 2020). Human errors don’t just impact one part of healthcare it impacts all aspects of it. It’s important on make sure that providers consider these errors when developing methods to ensure patient safety. Having an understanding of human errors as well as the necessary step is needed to be taken can help prevent human errors from reoccurring again. SEIPS was created to aid organizations in understanding all possible risk factors that create any possible threat to the organization and how to reduce them. In healthcare it’s important to understand how to reduce errors and prevent risks from happening when improving patient safety and care. Seven Types of Errors In any healthcare organization, there are errors that become present. Seven types of errors that can be present in a healthcare organization are organization and management errors, skill-based, rule-based, knowledge-based, decision errors, perceptual errors, and human errors. Organizational errors occur when management refuses to believe that they are at fault for certain events that happen or any issues that occur. For example, when a person in management makes an error in entering patient data and denies that they made a mistake. An error like this can be prevented if more caution is taken when putting in patient data, like double-checking the information. Skill-based errors are described as actions made with the r4esult of actions that were not intended. An example can be when a nurse administers the incorrect medication because they picked up the wrong syringe when preparing to insert the medication. This action can be dangerous as well as result in many disciplinary actions. This can be prevented, by double checking, even triple checking with other nurses, doctors, and staff before administering the drug. Rule-based errors are describing as actions that match the intentions, but do not result in the intended outcome because of an incorrect application of a rule or plan (Johnson & Sollecito, 2020). For example, removing a patient’s breathing because it was inserted correctly and this being before they can even breathe on their own. This can be prevented by having all staff members understand all the rules and procedures necessary to perform. Knowledge-based errors are described as an action that does not achieve the intended outcome due to knowledge deficits. For example, prescribing the incorrect medication to a patient without having the proper knowledge of the medication or the patient’s medical history. These knowledge-based errors aren’t common, but they can happen (Johnson & Sollecito, 2020). Decision errors are described as incorrect decisions that are made and result in errors. For example, going through with a surgery knowing that the patient isn’t stable enough to withstand the surgery and also knowing that this can lead to the patient’s death. These errors are very difficult to prevent because we don’t know what their course of action with their patients will be. Perceptual errors are described as errors caused by lack of judgement. For example, taking an x-ray of a patient and telling the patient the results before a radiologist can read the results and actually know what is going on. These errors can be prevented by just waiting for a radiologist to examine the results before speaking to the patient (Johnson & Sollecito, 2020). This takes us to our last errors, human errors. Human errors are the most concerning of errors because it can affect all the aspects of healthcare (Johnson & Sollecito, 2020). This form of errors is one that healthcare providers must take into account when creating systems and processes to ensure patient safety. In healthcare there are many forms of measure that are put into place to help improve patient safety. The Joint Commission is one of these measures put into place to help improve the quality of care as well as patient safety. The Joint Commission was designed with the purpose to examine all errors within healthcare organization and aid them with recommendations on various tools that can help ensure those improvements. It’s encouraged that hospitals conduct risk assessment on errors that occur within the hospital, particularly serious errors to help reduce any possible harm (Johnson & Sollecito, 2020). This commission developed the Patient Safety Event (Taxonomy) which was used to standardize terminology and classification schema for adverse events to develop a common language. Having such a tool can help find the root problem and figure out the best way to fix them. Framework of SIEPS Systems Engineering Initiatives for Patient Safety (SIEPS) helps break down errors that are made within a healthcare organization and it shows how accidents come about from the interaction of individuals, machines, and the environment (Johnson & Sollecito, 2020). SEIPS focuses on the 7 errors stated above to help improve human errors and create safety to help reduce these errors. The SEIPS model explains how the layout of the work program can affect the safety of patient as well as employee and organization outcomes (Johnson & Sollecito, 2020). CQI’s also offer healthcare organization with a decision-making tool in order to respond to the difficult dynamic relationships between the historical, socio-cultural, economic, and environmental elements of systems that give individuals opportunities and challenges (Carayon, et al., 2006). This tool is providing healthcare organization with error reduction and errors assessments efforts to achieve the intended outcome. Positive Effect The Systems Engineering Initiatives for Patient Safety (SIEPS) model positively effects on the reduction of errors within a healthcare organization because it permits the work to be impacted, but also provides patient safety as well as employees safety (Carayon et al., 2006). This model helps understand the skills and the knowledge of healthcare providers that are essential. SEIPS will help reduce the amount of errors within a healthcare organization through the focus of a system design and its result on processes and outcomes of process description of system, its components and interactions as well as how it impacts patient safety and employees/organization outcomes. Relationship of CQI and SEIPS Both SEIPS and CQI’s have the same purpose which is helping to produce the best quality outcome for healthcare organizations, while also assessing medical errors. These two can be used in a reporting system or to analyze events (Johnson & Sollecito, 2020). CQI’s offer healthcare organization with decision-making tools and feedback which help with complicated dynamic relationships linked to historical, socio-cultural, economic, and environmental elements of systems that allow individuals to new opportunities and challenges (Carayon, et al., 2006). It is essential to assess any medical errors in a healthcare setting in order to know how severe it as well as its effect on the organization. Reduction in errors and errors assessments are effective and efficient to help improve healthcare. SEIPS adds a better understanding of structures and process for positive outcomes to happen. When using both SEIPS and CQI’s it will help continue the process of improvement the reduction of errors as well as the quality of care. Conclusion In healthcare errors are very common and it is important to assess these errors before they become more severe. There are seven types of errors that can be present in a healthcare organization are organization and management errors, skill-based, rule-based, knowledge-based, decision errors, perceptual errors, and human errors. These errors can be prevented, but it takes skills, knowledge, and training to assess these errors. The Joint Commission is a measuring tool which has helped improve patient safety. SIEPS has helped break down errors that are made within a healthcare organization and it shows how accidents come about from the interaction of individuals, machines, and the environment. Also, its positive effects it has had in reducing errors within healthcare. When SEIPS and CQI’s come together they advance the process of improving the reduction of errors as well as the quality of care.