Abstract/Summary

Objective: Variable rate intravenous insulin infusion (VRIII) is a high-risk medication that has a potential to cause significant patient harm if used in error. Complex preparation of VRIII in clinical areas and the need for frequent monitoring and adjustment increase the complexity of using VRIII. An emerging approach, called Resilient Health Care, proposes understanding complexity of work by exploring how work is assumed to be done and compare it with everyday work. This study aimed to explore how VRIIIs are perceived to be used by healthcare practitioners, focusing on one aspect of RHC: understanding how work is assumed to be done by using a method called Hierarchical Task Analysis (HTA). Design: A qualitative study using document analysis and focus groups. Setting: A Vascular Surgery Unit in a UK tertiary, acute National Health Service (NHS) teaching hospital. Participants: Various stakeholders/users in different professional roles involved in the process of using VRIIIs. Results: The HTA showed the complexity of using VRIII and highlighted more than 115 steps required to treat elevated blood glucose. The process of producing hospital-specific guidelines was iterative. Careful consideration was taken to coordinate the development and implementation of guidelines. Documents provided detailed clinical instructions related to the use of VRIII but practitioners selectively used them, often in deference to senior colleagues. Intentional adaptations e.g. proactively asking for a VRIII prescription occurred and were acknowledged as part of providing individualised patient care. Conclusion: Using VRIII to treat elevated blood glucose is a complex but necessary process mediated by a range of factors such as organisational influences. Adaptive strategies to mitigate errors were common and future research can build on insights from this study to develop a broader understanding of how VRIIIs are used and to understand how adaptations are made in relation to the use of VRIII.