In “Patient Safety for Health Professionals,” it states, “Marie Wilson is a midd
ID: 126983 • Letter: I
Question
In “Patient Safety for Health Professionals,” it states, “Marie Wilson is a middle-aged, white woman with a 26-year history of type 1 diabetes mellitus. She had used an insulin pump for 14 years; however, her diabetes was suboptimally controlled, and the decision was made to upgrade her insulin pump. When Marie received the new pump, she contacted the clinic to set up an appointment to meet with the nurse practicioner, who was a certified diabetes educator and pump trainer. Because Marie was eager to start using the new pump, the training appointment was added to an already full clinic day. The clinic had no formal policies and procedures for initiating or upgrading insulin pump therapy. The patient programmed the pump with direct nurse practitioner supervision. The patient manually primed the new pump according to the procedure she used to prime her old pimp, and, with a blood sugar of more than 300 mg/dL, acted to deliver a bolus of rapid-acting insulin via the new pump. The patient then left the clinic to go to a meeting, but agreed to return later that day to meet with the nurse practitioner and the pump company representative (Representative A). The patient’s blood sugar was 467 mg/dL when she returned to the clinic that afternoon, and she administered a bolus of rapid-acting insulin subcutaneously by syringe. The nurse practitioner questioned a potential delivery problem and contacted the pump company’s help desk, who verified the settings and informed the nurse practitioner that a blood sugar of 300 would take awhile to come down. The patient left the clinic stating that she felt comfortable with the new pump. Representative A arrived at the clinic after the patient had left and reviewed questions with the nurse practitioner. The nurse practitioner asked Representative A to follow up with the patient that evening to check on her high blood sugars and ti answer questions about the new pump. He arranged for another company representative (Representative B) to do so. When Representative B contacted the patient that evening, the patient’s blood sugar had come down to around 200 mg/dL. The patient told Representative B that she felt like she was doing well with the pump. At bedtime, the patient’s blood sugar was >250 mg/dL, at which point she gave herself another bolus of insulin via the pump. The following morning, the patient contacted the physician to report severe nausea, vomiting, and a high blood sugar. The physician sent her to he emergency department, where she was admitted and treated for diabetic ketoacidosis. Representative B was asked to go to the hospital and evaluate the pump. She determined that the pump had been improperly primed, resulting in no insulin delivery.”
1. What would be an appropriate quality-improvement tool to address this incident?
2. What are the root causes leading to patient safety problems in this case?
Explanation / Answer
What would be an appropriate quality-improvement tool to address this incident?
TQM is the initial request of the scientific technique to procedure enhancement. TQM methods have been functional extensively in U.S. and Japanese manufacturing and in other administrations facing modest tests in a disciplined method to improve customer gratification. CQI is TQM practical inside health care.
The technique necessitates administrative leaders to create development goalmouths and to select projects that can realize precise enhancements. Cross-functional squads invent a flow chart of a procedure under education and use information to comprehend differences from excellence. The practice respects faults as crops of sick intended organizations, not as the responsibility of separate labors or bad apples. Once crews have advanced a cultured understanding of a procedure, they jump a four-step exercise:
-Strategize an involvement/assessment to advance the procedure.
-Do the conjectured intervention.
-Revision the consequences from the involvement.
-Action on the consequences, if promising, by institutionalizing the involvement; if unfavorable, by testing another involvement.
What are the root causes leading to patient safety problems in this case?
The work setting in which nurses deliver care to patients can regulate the excellence and security of patient care. As the major health care staff, nurses relate their knowledge, services, and knowledge to care for the numerous and altering requirements of patients. A great part of the stresses of patient care is placed on the effort of nurses. When care cascades short of principles, whether because of resource distribution or deficiency of suitable rules and principles, nurses assume much of the accountability. This replicates the sustained miscalculation of the better effects of the frequent, multifaceted health care schemes and the work setting issues. Also there is no protocol for the clinic for initiating or upgrading insulin pump therapy. Adding to that the clinic was already a crowded place. There was no proper patient education and follow up leading to safety problems.