1. Clinical Governance Support Unit
Insulin Work Stream
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Clinical Governance Support Unit

2. Reduce the Risk of Harm & Improve Patient Safety
What is it we are trying to do?
Reduce the Risk of Harm
&
Improve Patient Safety
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3. 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
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4. Insulin Management Plans Insulin Action Plan
Solutions so far
Insulin Management Plans
Insulin Action Plan
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5. 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?

7. 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.

8. Data Collection Tool
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9. Graph
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10. Run Chart
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11. Data Collection December 2011 to July 2012
Going back to Practice
Support
Testing – November 2011
Data Collection December 2011
to July 2012