Detailed analysis of 'work as imagined' in the use of intravenous insulin infusions in a hospital: a hierarchical task analysis.

OBJECTIVE: Variable rate intravenous insulin infusions (VRIII) is a high-risk medication that has a potential to cause significant patient harm if used in error. Complex preparation of VRIII in clinical areas and the need for frequent monitoring and adjustment increase the complexity of using VRIII. An emerging approach, called Resilient Healthcare, proposes understanding complexity of work by exploring how work is assumed to be done and compare it with everyday work. This study aimed to explore how VRIII is perceived to be used by healthcare practitioners, focusing on one aspect of Resilient Healthcare: understanding how work is assumed to be done, using a method called hierarchical task analysis (HTA). DESIGN: A qualitative study using document analysis and focus groups. SETTING: A vascular surgery unit in an acute National Health Service teaching hospital in the UK. PARTICIPANTS: Stakeholders/users in different professional roles involved in the process of using VRIII. RESULTS: The HTA showed the complexity of using VRIII and highlighted more than 115 steps required to treat elevated blood glucose. The process of producing hospital-specific guidelines was iterative. Careful consideration was taken to coordinate the development and implementation of guidelines. Documents provided detailed clinical instructions related to the use of VRIII but practitioners selectively used them, often in deference to senior colleagues. Intentional adaptations, for example, proactively asking for a VRIII prescription occurred and were acknowledged as part of providing individualised patient care. CONCLUSION: Using VRIII to treat elevated blood glucose is a complex but necessary process mediated by a range of factors such as organisational influences. Adaptive strategies to mitigate errors were common and future research can build on insights from this study to develop a broader understanding of how VRIII is used and to understand how adaptations are made in relation to the use of VRIII.

Understanding safety differently: developing a model of resilience in the use of intravenous insulin infusions in hospital in-patients-a feasibility study protocol.

BACKGROUND: Intravenous insulin infusions are considered the treatment of choice for critically ill patients and non-critically ill patients with persistent raised blood glucose who are unable to eat, to achieve optimal blood glucose levels. The benefits of using intravenous insulin infusions as well as the problems experienced are well described in the scientific literature. Traditional approaches for improving patient safety have focused on identifying errors, understanding their causes and designing solutions to prevent them. Such approaches do not take into account the complex nature of healthcare systems, which cannot be controlled solely by following standards. An emerging approach called Resilient Healthcare proposes that, to improve safety, it is necessary to focus on how work can be performed successfully as well as how work has failed. METHODS AND ANALYSIS: The study will be conducted at Oxford University Hospitals NHS Foundation Trust and will involve three phases. Phase I: explore how work is imagined by analysing intravenous insulin infusion guidelines and conducting focus group discussions with guidelines developers, managers and healthcare practitioners. Phase II: explore the interplay between how work is imagined and how work is performed using mixed methods. Quantitative data will include blood glucose levels, insulin infusion rates, number of hypoglycaemic and hyperglycaemic events from patients' electronic records. Qualitative data will include video reflexive ethnography: video recording healthcare practitioners using intravenous insulin infusions and then conducting reflexive meetings with them to discuss selected video footage. Phase III: compare findings from phase I and phase II to develop a model for using intravenous insulin infusions. ETHICS AND DISSEMINATION: Ethical approvals have been granted by the South Central-Oxford C Research Ethics Committee, Oxford University Hospitals NHS Foundation Trust and University of Reading. The results will be disseminated through presentations at appropriate conferences and meetings, and publications in peer-reviewed journals.

Awareness of Physicians and Clinical Pharmacists About ACC/AHA Guidelines for Dyslipidemia Management: A Cross-Sectional Study.

INTRODUCTION: Cardiovascular diseases (CVDs) are one of the leading causes of morbidity and mortality worldwide. Although genetics could contribute to the incidence of CVD, they are mostly acquired conditions. Management of precipitating factors such as hyperlipidemia can prevent CVD. Therefore, clinical guidelines have been used as a tool to improve patient outcomes and minimize practice variation. OBJECTIVE: The objective of this study was to assess health-care providers' (physicians and clinical pharmacists) awareness about the latest edition of the American College of Cardiology/American Heart Association (ACC/AHA) guidelines of dyslipidemia management. MATERIALS AND METHODS: To meet the study objective, a self-administered questionnaire was designed based on the recommendations of the latest edition of the ACC/AHA guidelines for dyslipidemia management. After validation, the questionnaire was distributed to physicians and clinical pharmacists in Al-Ahsa province of Saudi Arabia. RESULTS: Validation of the questionnaire was carried on 10 participants (Cronbach's alpha = 0.816). Seventy-seven participants completed the questionnaire (acceptance rate = 51.33%). The majority of participants knew about the release of the ACC/AHA 2013 guidelines for dyslipidemia (77% of the physicians and 48% of the clinical pharmacist). Inadequate knowledge of the major changes in the dyslipidemia management was observed in both study groups with no significant difference between them (the median score for physicians and pharmacists was 4 out of 10 with a range of 1-9, Z = -0.15, P = 0.88). CONCLUSION: Inadequate level of knowledge about practice-changing recommendations of the recent ACC/AHA guidelines for dyslipidemia management was observed among the study participants. This level of knowledge could result in clinical malpractice and worsen management outcomes. Thus, efforts should be in place to raise awareness about the evidence-based management of dyslipidemia and monitor compliance to guidelines and their implementation outcomes.