Medication errors in the intensive care unit: literature review using the SEIPS model

Area of Science:

• Patient Safety
• Health Systems Engineering
• Human Factors in Medicine

Background:

• Medication errors in intensive care units (ICUs) are a significant daily threat to patient safety, leading to potential injury or death.
• Effective medication safety requires a systematic approach that optimizes tasks, technology, environment, and organizational culture.
• The Systems Engineering Initiative for Patient Safety (SEIPS) model offers a framework for understanding complex critical care medication processes.

Purpose of the Study:

• To examine the research literature on medication errors in ICUs.
• To identify human factors and system-related contributors to medication errors.
• To propose a framework for developing multifaceted medication safety interventions.

Main Methods:

• Literature review integrating human factors principles with the structure-process-outcome (SPO) model of quality improvement.
• Analysis of research on critical care medication systems using the SEIPS model.

Main Results:

• Human factors such as stress, high workload, and knowledge/performance deficits are linked to medication errors.
• Systemic issues including frequent interruptions, communication breakdowns, and poorly integrated health information technology contribute to errors.
• The SEIPS model provides a valuable lens for analyzing these complex interactions.

Conclusions:

• Addressing medication errors in ICUs necessitates a comprehensive strategy that simultaneously targets human factors and systemic vulnerabilities.
• Multifaceted interventions are required to enhance patient safety in high-risk critical care environments.
• Integrating human factors and systems engineering principles is essential for robust medication safety.