Modelling the use of variable rate intravenous insulin infusions in hospitals by comparing Work as Done with Work as Imagined

Insulin errors and contributing factors affecting people with diabetes in hospital: A scoping review

BACKGROUND

Whilst insulin therapy errors are commonly reported in hospital and can cause significant negative outcomes for people with diabetes, there is no standardised approach to identifying when and why these errors occur within complex inpatient settings.

OBJECTIVE

This scoping review was conducted to explore and map the types and classification of reported insulin errors in the care of people with diabetes in hospital inpatient settings and to identify potential interacting components/factors associated with these errors.

RESEARCH DESIGN AND METHODS

The review followed the methodological approach of the Joanna Briggs Institute for scoping reviews. Published and unpublished literature (grey) in the English language were searched from January 2000 to July 2024 on Medline, CINAHL, Embase and other relevant websites. Eligible studies were those reporting insulin errors occurring in hospital during the treatment of people who had diabetes. A new framework was developed for examining insulin errors (RESILIENT - interacting-components-in-insulin-use-in-hospital). This was applied to categorise incidents and interacting components identified. Results were summarised graphically and descriptively.

RESULTS

A total of 124 peer-reviewed publications and reports were included. Only forty-nine studies attempted to classify the type of errors reported and they varied considerably in terminology and focus. Insulin errors were most frequently reported at the prescribing, administration, communication/documentation and medication review stages. Common factors associated with reported insulin errors included: time-critical coordination of insulin related tasks (for example coordination of glucose monitoring, meal delivery and mealtime insulin administration; prescribing and medication review; intravenous insulin infusion management); capability at point of care, staff knowledge, non-adherence to guidelines/recommendations; teamwork, communication gaps or errors; patient factors; organisational processes/systems, education and training; equipment (e.g. lack off system integration, right equipment at point of care).

CONCLUSIONS

The review highlighted considerable heterogeneity in approaches to identifying and classifying insulin errors in the literature. This review identified incidents occurring in areas of the insulin process which have been previously rarely explored. Further studies are needed, using standardised approaches which capture the complexity of insulin errors within the hospital system, to support the development of interventions which improve insulin safety. Use of RESILIENT Framework could offer a more standardised method of data collection and analysis of insulin errors.

REGISTRATION

The protocol was registered at the Centre for Open Science (https://osf.io/nmd8a).

SOCIAL MEDIA ABSTRACT

A novel approach to identifying, classifying & exploring insulin errors for people with diabetes in hospital @_ChristinaLange.

SHINE study: Developing an intervention for safe hospital insulin use for older or frail adults with diabetes undergoing surgical hospital admission: Study protocol

AIMS

To present a study protocol for the development of an intervention to enhance safe insulin use for older or frail adults undergoing a surgical admission to hospital.

DESIGN

Following the United Kingdom's Medical Research Council and National Institute for Health and Care Research Frameworks for development and evaluation of complex interventions; this qualitative study will use a co-design approach using design thinking, to develop a theoretical model for the intervention.

METHODS

Non-participatory observations, interviews and co-design workshops will be conducted with older or frail individuals with diabetes, their caregivers and healthcare staff responsible for their care during surgical admissions at a single National Health Service hospital in England. We will utilise their experiences and perspectives to establish priorities and generate ideas for the development of a conceptual model aimed at supporting the insulin safety review process in hospitals. Data will be analysed using framework analysis. People with diabetes were involved in the design of this study. The protocol was approved by the East-Midlands-Derby Research Ethics Committee (24/EM/0022). Study registered on Open Science Framework: https://osf.io/4wvu5.

RESULTS

Results of this study will be shared with study participants and disseminated through presentations at conferences/meetings and peer-reviewed publications.

CONCLUSION

This article outlines the methodology for the planned study which will employ a novel methodology to tackle the problem of hospital insulin safety. Its findings will contribute to a better understanding of the multiple interacting components implicated in hospital insulin use (patient, staff, context) and support further work around system-based strategies to enhance insulin safety resilience in hospital.

Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method

BACKGROUND

Hospital discharge is a complex process encompassing multiple interactions and requiring coordination. To identify potential improvement measures in care transitions for people with complex care needs, intra- and inter-organisational everyday work needs to be properly understood, including its interdependencies, vulnerabilities and gaps. The aims of this study were to 1) map coordination and team collaboration across healthcare and social care organisations, 2) describe interdependencies and system variability in the discharge process for older people with complex care needs, and 3) evaluate the alignment between discharge planning and the needs in the home.

METHODS

Data were collected through participant observations, interviews, and document review in a region of southern Sweden. The Functional Resonance Analysis Method (FRAM) was used to model the discharge process and visualise and analyse coordination of care across healthcare and social care organisations.

RESULTS

Hospital discharge is a time-sensitive process with numerous couplings and interdependencies where healthcare professionals' performance is constrained by system design and organisational boundaries. The greatest vulnerability can be found when the patient arrives at home, as maladaptation earlier in the care chain can lead to an accumulation of issues for the municipal personnel in health and social care working closest to the patient. The possibilities for the personnel to adapt are limited, especially at certain times of day, pushing them to make trade-offs to ensure patient safety. Flexibility and appropriate resources enable for handling variability and responding to uncertainties in care after discharge.

CONCLUSIONS

Mapping hospital discharge using the FRAM reveals couplings and interdependencies between various individuals, teams, and organisations and the most vulnerable point, when the patient arrives at home. Resilient performance in responding to unexpected events and variations during the first days after the return home requires a system allowing flexibility and facilitating successful adaptation of discharge planning.

An Intelligent Model-Based Effective Approach for Glycemic Control in Type-1 Diabetes

Type-1 diabetes mellitus (T1DM) is a challenging disorder which essentially involves regulation of the glucose levels to avoid hyperglycemia as well as hypoglycemia. For this purpose, this research paper proposes and develops control algorithms using an intelligent predictive control model, which is based on a UVA/Padova metabolic simulator. The primary objective of the designed control laws is to provide an automatic blood glucose control in insulin-dependent patients so as to improve their life quality and to reduce the need of an extremely demanding self-management plan. Various linear and nonlinear control algorithms have been explored and implemented on the estimated model. Linear techniques include the Proportional Integral Derivative (PID) and Linear Quadratic Regulator (LQR), and nonlinear control strategy includes the Sliding Mode Control (SMC), which are implemented in this research work for continuous monitoring of glucose levels. Performance comparison based on simulation results demonstrated that SMC proved to be most efficient in terms of regulating glucose profile to a reference level of 70 mg/dL compared to the classical linear techniques. A brief comparison is presented between the linear techniques (PID and LQR), and nonlinear technique (SMC) for analysis purposes proving the efficacy of the design.

Goal Conflicts, Classical Management and Constructivism: How Operators Get Things Done

In this study we identify the differences in goal realisation when applying two conflicting paradigms regarding rule perception and management. We gathered more than 30 scenarios where goal conflicts were apparent in a military operational unit. We found that operators repetitively utilized certain routines in executing their tasks in an effort to realize several conflicting goals. These routines were not originally intended nor designed into the rules and not explicitly included in documentation. They were not necessarily at odds with the literal wording and/or the intent of rules and regulations, although we did find examples of this. Our data showed that local ingenuity was created innovatively within the frame of existing rules or kept invisible to those outside the unit. The routines were introduced and passed on informally, and we found no evidence of testing for the introduction of new risks, no migration into the knowledge base of the organisation, and no dissemination as new best practices. An explanation for this phenomenon was found in the fact that the military organisation was applying a top-down, classical, rational approach to rules. In contrast, the routines were generated by adopting a constructivist view of rules as dynamic, local, situated constructions with operators as experts. The results of this study suggest that organisations are more effective in solving goal conflicts and creating transparency on local ingenuity if they adopt a constructivist paradigm instead of, or together with, a classical paradigm.

Using video reflexive ethnography to explore the use of variable rate intravenous insulin infusions

Background

The use of variable rate intravenous insulin infusion (VRIII) is a complex process that has consistently been implicated in reports of error and consequent harm. Investment in patient safety has focused mainly on learning from errors, though this has yet to be proved to reduce error rates. The Resilient Health Care approach advocates learning from everyday practices. Video reflexive ethnography (VRE) is an innovative methodology used to capture everyday practices, reflect on and thereby improve these. This study set out to explore the use of VRIIIs by utilising the VRE methodology.

Methods

This study was conducted in a Vascular Surgery Unit. VRE methodology was used to collect qualitative data that involved videoing healthcare practitioners caring for patients treated with VRIII and discussing the resulting clips with participants in reflexive meetings. Transcripts of these were subjected to thematic analysis. Quantitative data (e.g. blood glucose measurements) were collected from electronic patient records in order to contextualise the outcomes of the video-observed tasks.

Results

The use of VRE in conjunction with quantitative data revealed that context-dependent adaptations (seeking verbal orders to treat hypoglycaemia) and standardised practices (using VRIII guidelines) were strategies used in everyday work. Reflexive meetings highlighted the challenges faced while using VRIII, which were mainly related to lack of clinical knowledge, e.g. prescribing/continuing long-acting insulin analogues alongside the VRIII, and problems with organisational infrastructure, i.e. the wireless blood glucose meter results sometimes not updating on the electronic system. Reflexive meetings also enabled participants to share the meanings of the reality surrounding them and encouraged them to suggest solutions tailored to their work, for example face-to-face, VRIII-focused training.

Conclusions

VRE deepened understanding of VRIII by shedding light on its essential tasks and the challenges and adaptations entailed by its use. Future research might focus on collecting data across various units and hospitals to develop a full picture of the use of VRIIIs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07883-w.