Table 3

High-risk failures and potential solutions

FailureEffectHCausesFDCIRPN
Variability in the delivery of DM education and training
  • DM medication dosage education not fully understood by patient or caregiver

  • Patient delays contacting provider with questions

  • Patient experiences symptomatic hypoglycaemia (≤70 mg/dL) or symptomatic hyperglycaemia (250–349 mg/dL)

7Patient education
  • Duration of DM medication education inadequate

  • Poor timing of education as patient/caregiver is often overwhelmed and dealing with multiple discharge issues

Assessment
  • Lack of DM self-care competency assessment

10870560
Containment solution:
  • Hire additional DM educators; ensure staffing on nights and weekends

Permanent solutions:
  • Develop a standardised diabetes education and training toolkit with an electronic interface that allows for 24-hour delivery

  • Integrate individualised DM medication instructions within the EHR for immediate delivery to patients with low health literacy

  • Develop a DM self-care competency assessment to assure optimal postdischarge DM self-care

Variability in care coordination
  • Discharge instructions do not include follow-up with DM provider or primary care appointment

  • Follow-up appointment for DM does not take place

  • Patient experiences symptomatic hypoglycaemia (≤70 mg/dL) or symptomatic hyperglycaemia (>250–349 mg/dL)

7Care planning
  • Discharge can occur on weekends/off hours when clinic staff are not available

Human factors
  • Unanticipated discharge, unable to schedule appointment before discharge

10970630
Containment solution:
  • Manual verification of subspecialty appointments prior to discharge that align with patients’ availability/choice

Permanent solutions:
  • Automatic verification of subspecialty appointments prior to discharge that align with patients’ availability/choice

  • Advocate for multidisciplinary team care model and reimbursement model for care of multiple coexisting conditions at single visit

Variability in provider prescribing patterns
DM provider makes clinical judgement to send patient home without DM medication or on oral medication when insulin is neededPatient experiences symptomatic hypoglycaemia (≤70 mg/dL) or symptomatic hyperglycaemia (250–349 mg/dL)7Human factors
  • Clinician cognitive biases about risks and benefits of medications

Leadership/communication
  • Lack of physician consensus and standardisation of discharge DM medication protocol

101070700
Containment solutions:
  • Need to reach consensus and standardise discharge protocol for DM medications

  • Develop clinical decision support for standardised protocol for DM medications

Permanent solution:
  • Use historical, EHR patient-level data to develop personalised DM discharge medication plans

  • CI, Criticality Index; D, detection; DM, diabetes mellitus; EHR, electronic health record; F, frequency; H, harm; RPN, Risk Priority Number.