This article, titled “Modeling anesthesia medication delivery using the SEIPS 101 tools” by Elise DeForest and colleagues, delves into the complex nature of anesthesia medication administration within perioperative settings to enhance patient safety.
Background and Problem: Reducing patient harm during anesthesia medication administration has been a long-term goal in patient safety, as incidents like delivering the wrong drug, dose, or mislabeling remain relatively common. Individual errors contribute to harm in about one in twenty perioperative medications, with approximately 80% considered preventable. While various interventions have been suggested, primarily focusing on tools, technology, standardization, and communication, few have achieved widespread success in reducing medication harm. This suggests a need for a more sophisticated and comprehensive understanding of medication delivery systems. Traditional systems analysis techniques like Failure Modes Effects Analysis (FMEA) and Systems-Theoretic Process Analysis (STPA) have been applied, but they may not fully account for adaptations, local variations, non-linear effects, or generally how systems function successfully every day.
Study Objective and Methodology: The study’s primary objective was to use the Systems Engineering Initiative for Patient Safety (SEIPS) 101 tools to describe the anesthesia and perioperative medication delivery system. The SEIPS model is a well-used model for healthcare systems safety that conceptually represents the interconnectedness and interactions between people, tools and technology, tasks, and environment within a healthcare system. The recent publication of the SEIPS 101 tools offers a straightforward approach to mapping clinical systems. Data for this study was collected through direct observations of thirty-eight anesthetics, totaling over 100 hours, focusing on anesthesia providers’ common tasks and interactions with people, environments, tools, and technologies. Observation data, notes, interviews, and literature were then organized to create six SEIPS 101 tools demonstrating the complexity of anesthesia medication delivery:
- Anesthesia PETT Scan (People, Environment, Tools, and Tasks): Identifies facilitators and barriers associated with individual expertise differences, preferences, and potential conflicts among providers.
- Anesthesia People Map: Illustrates the wide range of relevant individuals involved in medication delivery and their interactions.
- Anesthesia Task x Tools Matrix: Depicts the broad range of interconnected processes and the tools used to provide anesthesia.
- Anesthesia Journey Map: Describes the chronological path used to deliver a medication through different stages of a surgical process.
- Anesthesia Work System Interactions Map: Identifies necessary interactions providers have with tools, tasks, people, and environment for successful anesthetics.
- Anesthesia Outcome Matrix: Describes various stakeholder experiences and outcomes that contribute to overall system complexity.
Key Findings and Insights: The application of the SEIPS 101 tools revealed that the anesthesia medication delivery system is complex and non-linear, involving multiple people, devices, information sources, locations, and outcomes.
- Facilitators and Barriers: The Anesthesia PETT Scan highlighted effective teamwork and communication as key facilitators, while barriers included differences in individual expertise, potential conflict between providers, cramped workspaces, tangled cords, and equipment issues. No task-related facilitators were identified, but the accumulation of multiple concurrent tasks was a significant barrier.
- Interconnectedness and Reliance: The tools demonstrated that successful patient care requires continuous reliance on the responses and actions of others, involving a wide range of individuals and interconnected processes. For example, the Anesthesia Task x Tools Matrix showed the numerous tools needed for various tasks, with gloves, the anesthesia machine, and the Pyxis medication cabinet being the most frequently used.
- Adaptation over Standardization: The study emphasizes that clinical expertise in safe medication delivery is not just about traditional clinical skills but also about the ability to adapt to variations in teams, tasks, technologies, processes, and desired outcomes. Different locations, tools, layouts, and supplies often require atypical approaches and uncommon, learned expertise, as standardization is not always possible or beneficial and can even be restrictive. There is “no one right way” to deliver anesthesia medications.
- Conflicting Outcomes: Different stakeholders (patient, family, provider, organization) experience various outcomes that are focused on different goals and people, contributing to overall system complexity. For instance, patient outcomes focus on health, while provider outcomes center on safe administration, quality of work life, and efficiency.
Implications for Patient Safety and Interventions: The findings have profound implications for understanding and improving medication harms:
- Debunking Individual Blame: The study firmly debunks the idea that success or failure can be solely attributed to one individual, event, or action, questioning the validity of causal attributions like “situational awareness failure” and “cognitive bias”. Instead, harms can be seen as a failure to adapt to new circumstances or appropriately trade off one outcome for another within a complex system.
- Rethinking Interventions: The SEIPS 101 tools offer valuable insights into why some interventions have produced mixed results. For example, while barcode scanning might increase safety, it can also increase interactions with devices or other tasks, leading to increased workload and potential shortcuts that create new pathways for adverse events. Similarly, standardization of labels might lead to syringe swaps due to newly developed shortcuts.
- Focus on Adaptation and System Enhancement: The results suggest that interventions would benefit from focusing on helping clinicians understand when and how best to adapt to new situations, rather than solely standardizing behaviors. It is beneficial to control unnecessary systemic variation while enhancing necessary variations in human behavior, emphasizing principles of monitoring, expectation, response, and learning.
- Future Directions: Future interventions could consider multifunctional devices that reduce the number of tools and system complexity, such as integrated anesthesia information management systems. This analysis also has implications for clinical decision-making support, urging a focus on the process of how clinicians make decisions, where they seek information, and how they weigh it, rather than just focusing on patient outcomes.
In conclusion, the SEIPS 101 tools, when deployed within a multidisciplinary team, can establish a shared understanding of the complexity of medication delivery, moving away from a sole focus on errors to a greater understanding of how complex clinical systems function successfully every day.
Reference: DeForest, E., Catchpole, K., Lusk, C., Abernathy, J. H., & Neyens, D. M. (2025). Modeling anesthesia medication delivery using the SEIPS 101 tools. Applied Ergonomics, 128, 104555. https://doi.org/10.1016/j.apergo.2025.104555