Clinical Governance Support Unit Insulin Work Stream Title Page Clinical Governance Support Unit

Reduce the Risk of Harm & Improve Patient Safety What is it we are trying to do? Reduce the Risk of Harm & Improve Patient Safety Title Page

Insulin – A High Alert Medicine High alert medicine – defined as a medicine that has highest risk of causing patient injury when misused. Insulin is included in top 10 high alert medicines world wide Potential for serious harm if not administered and handled properly Title Page

Insulin Management Plans Insulin Action Plan Solutions so far Insulin Management Plans Insulin Action Plan Title Page

Care bundle Measurement Sampling/Data collection Care Bundle Approach Care bundle Measurement Sampling/Data collection A care bundle is a structured way of improving processes of care to deliver enhanced patient safety and clinical outcomes. The process for achieving reliability is by testing individual measures to ensure they are the correct measures, and then testing a combination of measures (care bundle). Therefore the key measure in a care bundle in the composite score which measures the level of compliance with all measures for all patients. The data collection tool is a way of sampling whether optimum care is being delivered. What we are doing here is testing the reliability of the process, not testing if the treatment works – that’s been established. Can we do it here reliably? Working on the how – we do it – test – take the knowledge of the defects build into design You will use your local knowledge and skills to improve how the process works. If you have reliable processes you will achieve the outcome. What we don’t do is measure the reliability of our processes. We have developed a prototype for clinicians to test if it works Design for segment if it works take it out to services Three-five processes which when carried out together will improve the quality of care delivered. This is what nurse already do?

PRIMARY CARE Administration of Insulin This is the tool that we will use to collect our data. We have 4 process measures and 2 outcome measures. We sample 10 records to establish if each of the processes have been achieved and record on the chart with a yes/no answer. This will give you a score for each process measure and an overall compliance with the care bundle. REMEMBER this is about the reliability of care – that each patient receives all the elements in the care bundle all of the time.

Data Collection Tool Title Page

Graph Title Page

Run Chart Title Page

Data Collection December 2011 to July 2012 Going back to Practice Support Testing – November 2011 Data Collection December 2011 to July 2012