Using Prospective Analysis to Improve Quality Care in the Surgical Patient with Diabetes

Abstract

An insulin-using patient with diabetes who required surgery was identified by those caring for the individual to be at high risk of receiving fragmented care due to the focus of the admission being surgical. A formal review of our current process was undertaken using the Failure Modes and Effects Analysis (FMEA) methodology. Through this systematic review, potential failure modes and their potential effects were identified. These were ranked according to severity, frequency and detectability. Four major potential failures were identified: 1) pre-operative instructions were being given to the patient verbally, with no copy available for reference on the day of surgery; 2) the transfer of information from the OR to the internist providing post-operative care was lacking; 3) transfer of information from the pre-operative assessment to the post-operative internist providing care was lacking; 4) staffing of pharmacists at pre-admission clinics was inconsistent. The impact of these potential failures was that this group of patients arrived at the post-operative unit with poor management of their diabetes care resulting in patients requiring treatment for preventable problems, such as hypoglycemia. The outcomes of the FMEA process were: 1) implementation of a double copied medication instruction sheet completed during the pre-admission clinic visit with a copy provided to the patient and a copy placed on the chart; 2) a pre-printed order set, to be completed at the pre-admission visit, with orders for post-operative diabetes care to be implemented at the authorization of the anaesthetist and 3) review of pharmacy staffing in the pre-admission clinic.