Care delivery problems

Detecting the incidence and type of adverse drug events (ADEs) and medication errors is important for improving the quality of health care delivery. Problems include missing dose, wrong dose, frequency, and route errors. The consequence (ADE) of the errors depends on medication and patient factors as described previously. Some of these problems are organisational and related to chart order system and prescribing. 

Different templates such as timeline, tabular timeline or narrative chronology Done naturally at the gathering and mapping steps, problems noted as either care delivery problem or service delivery problem... 

Structured interviews with key members of staff are then undertaken to establish the chronology of events, the main care delivery problems and their respective contributory factors, as perceived by each member of staff. The key questions are What happened (the outcome and chronology) How did it happen (the care delivery problems) and Why did it happen (the contributory factors). Examples of care delivery problems and a summary of the process are shown in Boxes 8.3 and 8.4. 

BOX 8.4 A summary of the process of investigation and analysis Care Delivery Problems (CDPs)... 

The first step in any analysis is to identify the care delivery problems. These are actions or omissions, or other deviations in the process of care which had a direct or indirect effect on the eventual outcome for the patient. 

For each care delivery problem identified, the investigator records the salient clinical events or condition of the patient at that time (e.g. bleeding heavily, blood pressure falling) and other patient factors affecting the process of care (e.g. patient very distressed, patient unable to understand instructions). 

While a considerable amount of information can be gleaned from written records, interviews with those involved are the most important method of identifying the contributory faaors. This is especially so if the interview systematically explores these factors and so allows the member of staff to collaborate in the investigation. In the interview, the story and the facts are just the first stage. The staff member is also encouraged to identify both the care delivery problems and the contributory factors, which greatly enriches both the interview and investigation. 

Table 8.2 Care delivery problem there was delay in recognizing the seriousness of the patient s complaint...

Incidents that may harm patients are related to the health organization but also to contributory factors, care delivery problems and missing defenses and barriers (fig. 1). We learned in the past years a lot from civil aviation how a safety culture can be established. In medical education, beside a teaching culture we need a feedback culture to change the behavior and make people report unexpected outcomes in their field, and to end up with a safety culture. 

The commercialization of developments in biotechnology will require a new breed of chemical engineer, one with a solid foundation in the life sciences as well as in process engineering principles. This engineer will be able to bring iimovative and economic solutions to problems in health care delivery and in the large-scale implementation of advances in molecular biology. 

It is commonly found that patients with multiple medical problems may be taking as many as 10 to 15 drugs concomitantly. It is also becoming increasingly obvious to physicians, and other members of the health-care delivery team, that many drug combinations, when used inappropriately and injudiciously, have the inherent potential to interact adversely, leading to side effects and even death (see Chapter 4). 

Irrespective of the exact numbers, whether 50,000 or 100,000 deaths per year, preventable medical injury is a serious problem. For health care leaders, the message is clear allowing system vulnerabilities to cause harm to patients is unacceptable. Academicians may continue to debate methodology, but the leader s job is to focus on the design and implementation of stife care delivery systems. 

The devastating problem of medical error has forever changed the lives of too many patients and providers. Creating a culture of safety, a culture of harm-free care delivery, is the only course of action for the health care leaders of today and tomorrow. Its achievement rests on a profound change, and its creation is the duty of today s health care leaders. As leaders, we have learned and continue to learn from those we have served and failed and from providers who were giving care when systems failed them. 

Product or process selection needs to be done carefully. If the VSM limits are set too narrow, we may miss some big opportunity improvements. If the limits are set too large, we spend a lot of time going way beyond anything that will help the process under consideration. We end up trying to solve world hunger. The product or service selected for mapping should be one that has established a history of problems, such as delivery problems, quality failures,... 

Application of the test substance to the test system is without doubt the most critical step of the residue field trial. Under-application may be corrected, if possible and if approved by the Study Director, by making a follow-up application if the error becomes known shortly after the application has been made. Over-application errors can usually only be corrected by starting the trial again. The Study Director must be contacted as soon as an error of this nature is detected. Immediate communication allows for the most feasible options to be considered in resolving the error. If application errors are not detected at the time of the application, the samples from such a trial can easily become the source of undesirable variability when the final analysis results are known. Because the application is critical, the PI must calculate and verify the data that will constitute the application information for the trial. If the test substance weight, the spray volume, the delivery rate, the size of the plot, and the travel speed for the application are carefully determined and then validated prior to the application, problems will seldom arise. With the advent of new tools such as computers and hand-held calculators, the errors traditionally associated with applications to small plot trials should be minimized in the future. The following paragraphs outline some of the important considerations for each of the phases of the application. 

After the chromium (II) chloride solution has been transferred to flask B, the flow of ammonia through the reaction vessel should be started. The ammonia delivery tube should approach but not dip below the liquid level in flask B. If tank ammonia is used, the tank should be opened carefully to avoid spattering of liquids by a sudden burst of gas. If ammonia is to be generated, the ammonium sulfate solution should be added carefully to the potassium hydroxide in flask C. It may be necessary to cool flask C with ice at first, then to warm the generator later in order to maintain a reasonably constant flow of ammonia. The use of tank ammonia avoids these problems. If zinc was used in the reduction, a precipitate of zinc hydroxide forms first and redissolves. The violet-blue solution stirred at 0° is saturated with ammonia, then a 2- to 3-g. sample of the platinum catalyst is added rapidly to flask B. A strong countercurrent of nitrogen is used to prevent entrance of air into the system when the catalyst is added. The reaction mixture is allowed to stir for one hour while the flask is cooled with ice. 

Diuretics and their mechanisms of action will be discussed in detail in Chapter 21. Loop diuretics, such as furosemide (Lasix), block the Na" -K" -2CLsymporter in the ascending limb of the loop of Henle.The resultant effect is delivery of more Na" to the distal tubule and enhanced urinary loss of Na" and water. Unfortunately, the resultant increase in urinary excretion of and K+ can lead to arrhythmias. The potential for arrhythmias is exacerbated by the loss of Mg++ and Ca++ and an underlying vulnerability of the myocardium in CHF. However, loop diuretics are still part of the mainstay of therapy for CHF despite these potential problems and the absence of well-controlled multicenter clinical trials. The rationale for their use is so compelling that placebo-controlled studies appear unethical. Moreover, furosemide was accepted as the standard of care in all of the clinical trials that form the basis for recommended therapy for CHF. The use of the potassiumsparing diuretic spironolactone has been shown to improve survival and is discussed below. 

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