Safer Type 1 Diabetes Care at Home: SEIPS-based Process Mapping with Parents and Clinicians.

Area of Science:

• Pediatric Patient Safety
• Health Services Research
• Systems Engineering in Healthcare

Background:

• Pediatric medical errors in outpatient settings, including home care, are frequent.
• Children with type 1 diabetes (T1D) face medication errors and treatment delays.
• This study is the initial phase of the Ambulatory Pediatric Patient Safety Learning Lab.

Purpose of the Study:

• To identify failures contributing to medication errors and treatment delays in outpatient children with T1D.
• To explore potential solutions for enhancing patient safety in pediatric T1D management.
• To address critical gaps in care delivery for children with T1D at home.

Main Methods:

• Employed a transdisciplinary team (parents, safety researchers, clinicians).
• Utilized Systems Engineering Initiative for Patient Safety (SEIPS) based process mapping.
• Collected data via in-home medication review, observation, chart reviews, parent surveys, and Failure Modes and Effects Analysis (FMEA).

Main Results:

• 14 children experienced 18 medication errors (31 per 100 medications); 4 errors caused harm, 13 had potential for harm.
• High-risk errors occurred during clinic-home communication and home management.
• FMEA identified interventions for improved family communication and home care support during illness.

Conclusions:

• Multimodal methods and SEIPS-based process maps confirmed common medication errors and treatment delays.
• Enhanced home-based acute illness management support is crucial.
• Improved communication channels between clinics and families are high-yield interventions for pediatric patient safety.