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Multidisciplinary team focuses on making
care safer for patients receiving insulin
By Joan E. Shook, M.D.
As part of our patient safety program, I frequently visit units and
departments to chat with frontline caregivers about any patient
safety concerns they have identified or processes they believe could
be made safer. During these “walkarounds,” caregivers are encouraged
to openly share their thoughts and ideas regarding patient safety.
As a result of input obtained during a recent walkaround and
recommendations from the Joint Commission, the Patient Safety
Executive Group sanctioned a multidisciplinary team to evaluate the
processes surrounding the care of hospitalized patients receiving
insulin. This team, led by Karen Gurwitch, director of Pharmacy,
includes representatives from the Endocrine service, Nursing,
Pharmacy, Patient Safety and Risk Management. The team is charged
with evaluating the current process, making recommendations for
improvement and implementing change.
Although the work of the team is not yet complete, I want to commend
them on their hard work and dedication to making the processes
around insulin administration and management safer for the patients
at Texas Children’s Hospital. To date, the team’s work has centered
on:
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Modification and standardization of documentation on the Medication
Administration Record and the Diabetic Flow sheet for insulin.
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Development of a standardized order set and practice guidelines for
all patients receiving insulin.
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Development of several educational resources for both nursing and
pharmacy, including an on-line training module related to the care
of patients receiving insulin.
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Selection of a insulin pump for patients who are receiving insulin
via pump at home and require admission to Texas Children’s.
Currently, these patients must be managed while hospitalized without
the use of an insulin pump, and selecting and purchasing insulin
pumps for inpatient use can maintain the continuum of care when
appropriate.
Your support of these important improvements will be greatly
appreciated as they begin to roll out in the next few months. Please
join me in acknowledging the accomplishments of the team as we all
continue to strive to provide the safest care possible. If you have
any questions regarding the work of this team, please do not
hesitate to contact Karen Gurwitch or myself.
Joan E. Shook, M.D., is chief safety officer and chief of
Emergency Medicine at Texas Children’s Hospital and professor of
pediatrics and head of Pediatric Emergency Medicine at Baylor
College of Medicine. |
