Controls in the Nicu

WAC #2

November 05, 2016

Controls in the NICU

70

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        The diagram above shows how the normal routine of the blood thinner vials, Heparin and Hep-lock, in the California hospital. The reinforcing loop indicates an unstable environment of the way the drug is handled. One small change within the system could lead to potential problems for the patients involved and the business of the hospital afterwards. The staff largely depends on the due diligence of the staff responsible for the step before theirs. An example would be the nurse passing on the responsibility of validating the medication to be correct and is in the correct storage compartment to the medical technician. The staff seems to rely solely on the color of the medication label and thus only partly validating the correct medication for the patient. The only control that is seen in the incident to address information quality would be the color of the medication being placed to the correct storage compartment. The succeeding staff responsible for administering the medication to the patient then half-attempts to validate the correct medication through the color label to address operational process quality. Variations of service are likely to occur because changes are not accounted for.

Moreover, the system becomes a causal loop with a “cycle of violence” when there is a change in the label or quality of the medication delivered. An example would be the changing of the color of the labels of both Heparin and Hep-lock which led to the medical malpractice related to the Quaid twins. Because there is a lack of controls being used in the system, there is a high chance of the system to be ineffective because unforeseen changes can prevent the system to do the right thing even though they are efficient by doing the procedure correctly. This hampers their excellence on doing the right thing the first time, which is every time for each patient they attend to. It is essential to reduce these variations of quality by centering the hospital to the needs of the patients. The inadequate controls present at the time when the Quaid Twins incident occurred makes the medical healthcare system they are using not sustainable in providing quality healthcare.