In “Patient Safety for Health Professionals,” it states, “Marie Wilson is a midd
ID: 127319 • 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?
3. What are some system improvements that could be implemented to address the identified root causes?
Explanation / Answer
1Ans.
Representatives directly should not contact the patient directly and ask them to use it. even patient should not use the new pump until unless she confirm the effectiveness of the same, though she is using the same kind since long time. The company representatives should approach physician first and explain them about the pump function. Physician should also see the research on pump and it's effect, if he feels ok i will work then he will advie patients to use it.
2Ans
Improper approach
patient is excited using the new pump and so hurry in her work also, ignored on her sugar levels til she end up with some complications
Nurse practitioner may not aware of the pump functioning, directly experiemnting on her.
It has functioned well,
3Ans.
Check the pump calliberation and their functioning
Approach the physician first and explain about how to use pump with all the health care staff members
Make a pamplets how to use
In this sceniariot patient end up with some complications so pump has not worked well, so check whether she has used pump in a right way ot not. if it isnot used in right way explain her to use it, if it is a problem with the pump send it back to the company to modify and develop new pump.
It is going to be legal problem, if it is not working properly. get certification for that to sell it in the market.