Exercise 111: Team K Safe Injection Practices With One Syrin

Exercise 111 Team K Safe Injection Practices One Syringeone Drug

Exercise 11.1 - Team K: Safe Injection Practices: One Syringe/One Drug: Review Nevada health District 2008 Lawsuit Objective: To plan a rapid cycle improvement project using the IHI improvement model. Instructions: Students will conduct a 4-day rapid cycle improvement project for the following problem: Food in the refrigerator is often not eaten by the "best before" date and has to be thrown out. Students must start the project by answering the three questions: What am I trying to accomplish? How will I know the change is an improvement? What change can I make that will result in improvement? Differentiate how, when, and why to use different improvement models.

Paper For Above instruction

Introduction

Efficient and safe healthcare practices are essential components of patient safety and public health. One crucial aspect is ensuring that injection practices adhere to safety guidelines, specifically the "One Syringe/One Drug" rule, to prevent cross-contamination and the transmission of infectious diseases (CDC, 2020). The Nevada health District's 2008 lawsuit highlighted the importance of strict adherence to safe injection practices, emphasizing the need for ongoing quality improvement initiatives (Nevada Health District, 2008). Utilizing the Institute for Healthcare Improvement (IHI) improvement model enables healthcare teams to implement rapid cycle improvements effectively, fostering safer practices and reducing preventable errors.

Background and Context

Safe injection practices are fundamental to infection control in healthcare settings. The "One Syringe/One Drug" policy mandates that each syringe used for medication administration is used only once for a single patient and with a single drug, preventing contamination and infection transmission (WHO, 2017). Despite regulations, breaches often occur due to misunderstandings or systemic issues, leading to adverse events. The Nevada lawsuit in 2008 underscored the consequences of lapses in safety protocols and the necessity for continuous quality improvement (Nevada Health District, 2008).

Applying the IHI Improvement Model

The IHI Model for Improvement is a well-established framework used extensively in healthcare to accelerate improvement efforts. It is grounded in three fundamental questions:

1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in improvement?

A key feature of the model is the use of Plan-Do-Study-Act (PDSA) cycles, which facilitate rapid testing of changes in real-world settings (Langley et al., 2010). This approach encourages iterative learning, enabling teams to identify effective interventions swiftly while minimizing risks.

Implementing Rapid Cycle Improvements

The first step involves clarifying the aim of the project, such as reducing the incidence of unsafe injection practices by increasing staff compliance with established protocols. Next, measurable indicators—such as the percentage of staff correctly following procedures—are identified to monitor progress.

The initial PDSA cycle might involve introducing a targeted educational session about safe injection practices. The team then observes whether this intervention improves staff adherence. Data collected would analyze compliance rates before and after the intervention, guiding subsequent adjustments. For example, if compliance improves but is still suboptimal, additional measures like visual reminders or process changes could be tested in subsequent cycles.

Time-bound cycles of 2-4 days are typical for rapid improvement efforts, allowing quick assessment and adjustment. This iterative process continues until the desired safety level is achieved, exemplifying continuous quality improvement (NHS Improvement, 2018).

Differentiation of Improvement Models

While the IHI model emphasizes rapid, iterative PDSA cycles, other models serve distinct purposes:

• DMAIC (Define, Measure, Analyze, Improve, Control): Used predominantly in Six Sigma for process optimization over longer periods (Antony et al., 2019). It is data-driven and structured, suitable for complex, measurable processes.
• Lean methodology: Focuses on value stream mapping to eliminate waste, promoting efficiency (Womack & Jones, 2003). It is effective for streamlining workflows but differs from the rapid testing approach of PDSA.
• FMEA (Failure Mode and Effects Analysis): A proactive risk assessment tool used to identify potential failures before they occur (Stamatis, 2003). It is strategic rather than iterative.

Choosing the appropriate model depends on the specific issue, urgency, and context. For infectious control and practice improvements, rapid cycle PDSA testing is often most effective due to its flexibility and speed.

Conclusion

Implementing safe injection practices is vital for patient safety, especially following legal and regulatory alerts like the Nevada lawsuit of 2008. The IHI improvement model provides a systematic, rapid approach through PDSA cycles to test and implement changes that can enhance compliance and reduce risks. Differentiating this model from others such as DMAIC or Lean allows healthcare organizations to select the most appropriate framework for their unique needs, ultimately fostering a culture of continuous improvement and safety adherence.

References

• Antony, J., Snee, R., & Ho, L. (2019). Six Sigma in Healthcare. International Journal of Quality & Reliability Management, 36(1), 1-19.
• Centers for Disease Control and Prevention (CDC). (2020). Preventing Transmission of Infectious Diseases in Healthcare Settings. CDC Guidelines.
• Langley, G. J., Moen, R., Nolan, T. W., Norman, C. L., & Provost, L. P. (2010). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass.
• Nevada Health District. (2008). Lawsuit and Safety Enforcement Report. Nevada Health District Publications.
• NHS Improvement. (2018). The Model for Improvement: How to Improve. NHS UK.
• Stamatis, D. H. (2003). Failure Mode and Effect Analysis: FMEA from Theory to Execution. ASQ Quality Press.
• Womack, J. P., & Jones, D. T. (2003). Lean Thinking: Banish Waste and Create Wealth in Your Corporation. Free Press.
• World Health Organization (WHO). (2017). WHO Guidelines on Hand Hygiene in Health Care. WHO.