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. 2023 May 22;8(3):e649.
doi: 10.1097/pq9.0000000000000649. eCollection 2023 May-Jun.

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

Eric S Kirkendall  1   2   3 , Patrick W Brady  4   5   6 , Sarah D Corathers  5   6   7 , Richard M Ruddy  6   8 , Catherine Fox  7 , Hailee Nelson  6   7 , Tosha B Wetterneck  9 , Isabelle Rodgers  10   11 , Kathleen E Walsh  10   11
Affiliations

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

Eric S Kirkendall et al. Pediatr Qual Saf. .

Abstract

Introduction: The limited data indicate that pediatric medical errors in the outpatient setting, including at home, are common. This study is the first step of our Ambulatory Pediatric Patient Safety Learning Lab to address medication errors and treatment delays among children with T1D in the outpatient setting. We aimed to identify failures and potential solutions associated with medication errors and treatment delays among outpatient children with T1D.

Methods: A transdisciplinary team of parents, safety researchers, and clinicians used Systems Engineering Initiative for Patient Safety (SEIPS) based process mapping of data we collected through in-home medication review, observation of administration, chart reviews, parent surveys, and failure modes and effects analysis (FMEA).

Results: Eight (57%) of the 14 children who had home visits experienced 18 errors (31 per 100 medications). Four errors in two children resulted in harm, and 13 had the potential for harm. Two injuries occurred when parents failed to treat severe hypoglycemia and lethargy, and two were due to repeated failures to administer insulin at home properly. In SEIPS-based process maps, high-risk errors occurred during communication between the clinic and home or in management at home. Two FMEAs identified interventions to better communicate with families and support home care, especially during evolving illness.

Conclusion: Using SEIPS-based process maps informed by multimodal methods to identify medication errors and treatment delays, we found errors were common. Better support for managing acute illness at home and improved communication between the clinic and home are potentially high-yield interventions.

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Conflict of interest statement

Kathleen Walsh within the past 36 months has served as a consultant for Sanofi and Research Triangle Institute. All the other authors have no financial interests to declare in relation to the content of this article.

Figures

Fig. 1.
Fig. 1.
SEIPS-based process map with errors for adjusting medications due to suboptimal control.
Fig. 2.
Fig. 2.
SEIPS-based process map with failure modes for managing type 1 diabetes during a concomitant serious illness*.
Fig. 3.
Fig. 3.
Key driver diagram, including aims and interventions.
See this image and copyright information in PMC

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