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

Abstract

BackgroundIntravenous 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 analysisThe 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 disseminationEthical 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.

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

“…The study results provided a deep understanding of the reality of WAI. The next stage is to conduct video observations 20 in order to understand how guidelines are used in practice, situations where the guidelines could not be delivered as written, type of challenges and context-dependent adaptations and to explore the gap/misalignments between WAI and WAD in order to find strategies to minimise the gap to improve patient care delivery.…”

“…19 This study is part of a wider project for which there is a published protocol. 20 There have been many research studies discussing the quality of different process modelling approaches. 21 22 Although a sequential flow diagram is considered the most commonly used process mapping approach in healthcare, there have been precedents for using hierarchical task analysis (HTA) for analysing and mapping complex healthcare systems.…”

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

“…Participant recruitment was conducted over 5 months. Based on the published study protocol [ 19 ], the aim was to include two patients and all healthcare practitioners responsible for the use of VRIII in their care. Table 1 shows the eligibility criteria and the recruitment process for both patients and healthcare practitioners.…”

“…The present study is part of a project that has a published protocol [ 19 ] with the overarching aim of exploring RHC in the use of VRIII. As far as we know, no previous study has used VRE methodology to explore WAD in the use of VRIII.…”

A Framework to Strengthen Learning Culture and Safeguards

“…Safety-II has been widely adopted by various industries as part of their organizational learning practice [35][36][37][38][39][40][41][42]. In contrast, the Safety Differently concept has streamlined safety practices by emphasizing bottom-up methods to involve workers when deciding on rules and safe working practices [43], advancing performance by repealing bureaucracy [44][45][46] and enhancing learning from an event during investigation [47]. Furthermore, the learning application can proactively identify any improvement opportunities, i.e., when something does not feel right or has people concerned that there are ways to improve a situation, findings from verification activities, and other improvement opportunities identified during post-job reviews.…”