Resilient Health Care in the use of intravenous insulin infusions

Variable rate intravenous insulin infusions (VRIIIs) are used to treat elevated blood glucose in severely ill hospitalised patients and those with diabetes missing more than one meal. VRIIIs can cause serious harm to the patient if used incorrectly. Conventional approaches to increasing safety have focused on linear thinking by first identifying errors, then finding solutions to prevent future recurrence. Resilient Health Care proposes improving patient safety by understanding the variability in everyday clinical work in order to realign ‘Work as Imagined’ (WAI): what people say, or think they do, with ‘Work as Done’ (WAD): what people actually do in practice. This study aimed to explore resilience in the use of VRIII in adult inpatients by comparing WAI with WAD. WAI was explored by analysing VRIIIs guidelines and focus groups with different stakeholders involved in the process of using VRIIIs. WAD was explored by first videoing healthcare practitioners while using VRIII, selecting video clips and discussing them with participants in reflexive meetings, then transcribing and analysing the reflexive meeting discussions. Two hierarchical task analyses (HTA) were developed to systematically represent WAI and WAD. Although most of the tasks in WAD HTA generally aligned with WAI HTA, some misalignments were observed. Misalignment was identified in different type of tasks including emergent, complex tasks as well as simple and complicated tasks. The majority of the observable adaptations used to respond to emergent tasks were forced adaptations or temporary workarounds where ideal solutions were not possible at that time.