A RCA on Vulnerabilities of Insulin Naïve Patients in Preventing Sentinel Events

Successful implementation of lockdown of insulin order entry. Four monthly prescription and chart audit conducted shows the utilization of insulin categories for new starts, appropriate consult, and materials needed for effective patient diabetic education resulting in zero sentinel events. The sustainment approach was done through feedback and close-loop communication with stakeholders. Review and analysis of processes related to insulin physician order entry system (POES) for Outpatient Clinics and explore methods that can assist providers and pharmacy staff in recognizing new insulin start among insulin naïve patients to ensure dosing appropriateness. Improve patient diabetic education provided by Licensed independent providers, Clinical and Primary aligned care team pharmacists, diabetic educators, and nursing staff. This session improves communication among multidisciplinary team members in the high-level engagement of insulin naïve patient and their families.

Problem: The prevention of sentinel events among insulin naïve patients due to the Complexity of Computerized provider ordering entry and communication gap between the provider, nursing staff, clinical pharmacist, primary aligned care team pharmacist, diabetic educator, and patients and their families

Measurement: Using root cause analysis principle: The RCA used 5 Why’s, Cause and Effect approach, and Rules of Causation. The Swiss cheese model assisted in the final understanding of events that identified multiple gaps and areas of systemic weakness

Analysis: The gaps identified in the final understanding were treated with the triage questions, supplemented by interviews, observations/ GEMBA walks. Unanswered gaps lead to causal analysis using the 5 whys and rules of causation

Implementation: Executive concurrence was secured on all Actions and Outcome measures to implement medication safety lockdown on all insulin ordering categories. Creation of a quick order menu with consult link to PACT Pharmacist and Diabetic educator. Implement and sustain staff training, diabetic education materials repository, and annual competencies

Patient Safety Clinician at STXVHCS
Patient Safety Clinician – STXVHCS

Speaker Type: Poster Presentations On-Demand

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