These are the three case studies I have chosen to use for the assignment.
Management and teams case study
Total Parental Nutrition (TPN) was not available on the paediatric Intensive Care Unit (PICU). Three Patients where without TPN for 8 hours, until same day order was placed as urgent for delivery.
Upon investigation, it was discovered that although the order had been placed the day before, the order confirmation was not checked by the pharmacist. The pharmacist stated that high workload was a contributing factor to this. This had already been escalated to the senior management of pharmacy team for review. The PICU was a level three unit with 12 intensive care beds. There was a national standard which required a 1.8 WTE pharmacist to provide a seven day service. The current staffing resource for PICU was 0.3 WTE, based on a 5 day clinical service. As the pharmacist support did not meet the required standards, this has led to a lack of specialist support to the unit of to WTE. Although there was a senior pharmacist lead for PICU, the pharmacist had a level of competency but was found to not be able to work at mastery level due to conflicting priorities.
The retention rate of pharmacy staff was very poor.
It was identified that there was a need for additional 2 WTE specialist pharmacist was needed for PICU.
Five Whys
TPN not available for three patients on PICU
Problem: TPN order confirmation was not checked by the pharmacist
Why?: This was a direct result of a very high workload for the pharmacist. There was pressure on pharmacist to deal with conflicting priorities.
Why?: The current staffing resource did not meet the national standard for PICU
Why?: Gap of two WTE was against national Standard.
Why? There was a chronic underfunding for pharmacist on the unit.
Why?: The gap in service was not identified due to failure to identify service requirement on PICU- Root cause.