Application of the SEIPS Model to Analyze Medication Safety in a Crisis Residential Center.

PURPOSE: Medication safety and error reduction has been studied in acute and long-term care settings, but little research is found in the literature regarding mental health settings. Because mental health settings are complex, medication administration is vulnerable to a variety of errors from transcription to administration. The purpose of this study was to analyze critical factors related to a mental health work system structure and processes that threaten safe medication administration practices.

BACKGROUND: The Systems Engineering Initiative for Patient Safety (SEIPS) model provides a framework to analyze factors affecting medication safety. The model approach analyzes the work system concepts of technology, tasks, persons, environment, and organization to guide the collection of data.

METHODS: In the study, the Lean methodology tools were used to identify vulnerabilities in the system that could be targeted later for improvement activities. The project director completed face-to-face interviews, asked nurses to record disruptions in a log, and administered a questionnaire to nursing staff. The project director also conducted medication chart reviews and recorded medication errors using a standardized taxonomy for errors that allowed categorization of the prevalent types of medication errors.

RESULTS: Results of the study revealed disruptions during the medication process, pharmacology training needs, and documentation processes as the primary opportunities for improvement. The project engaged nurses to identify sustainable quality improvement strategies to improve patient safety.

CONCLUSION: The mental health setting carries challenges for safe medication administration practices. Through analysis of the structure, process, and outcomes of medication administration, opportunities for quality improvement and sustainable interventions were identified, including minimizing the number of distractions during medication administration, training nurses on psychotropic medications, and improving the documentation system. A task force was created to analyze the descriptive data and to establish objectives aimed at improving efficiency of the work system and care process involved in medication administration at the end of the project.