Final WIKI Project-Group 14

Hypoglycemia, The Event You Never Saw Coming : 

Hypoglycemia, The Event You Never Saw Coming NSG505 Crudup, Shamitre; Green, Raymond; Hull, Tashanta

What Are “Never Events”? : 

What Are “Never Events”? "According to the National Quality Forum (NQF), “never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility." http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863

Hypoglycemia in the hospital, A Never Event : 

Hypoglycemia in the hospital, A Never Event Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility was placed on the list of never events because with proper care and glucose monitoring and controlling, hypoglycemia and its adverse affects can be avoided.

Hypoglycemia : 

Hypoglycemia According to the National Quality Forum hypoglycemia is defined as a "physiologic state in which the blood sugar falls below 60 mg/dl and physiological and/or neurological dysfunction begins." http://www.qualityforum.org/

hypoglycemia : 

hypoglycemia "Hypoglycemia occurs when your body's sugar (glucose) is used up to quickly. Glucose is released into the bloodstream too slowly. Too much insulin is released into the bloodstream. Insulin is a hormone that reduces blood glucose. It is produced by the pancreas in response to increased glucose levels in the blood. Hypoglycemia is relatively common in persons with diabetes." Once the blood glucose becomes too low the patient can slip into a diabetic coma or die. http://www.righthealth.com/Health/What%20Is%20Hypoglycemia-s?lid=yhoo-ads-sb-7460722696

Causes of Hypoglycemia : 

Causes of Hypoglycemia 1. Mismatch in the timing amount or type of insulin ant the carbohydrate intake. 2. Undernutrition 3. A history of severe hypoglycemia 4. renal failure 5. liver disorders 6. glucocorticoid or catecholamine deficiences 7. leukemia (caused by a possible abnormality in glucose metabolism 8. Others at risk are those that have ingested large amounts of alcohol and those who have surgery with general anesthesia http://spectrum.diabetesjournals.org/content/18/1/39.full.pdf+html?sid=da04d718-623c-4f27-8c60-e364d030aa54

Whose Problem?The Patient : 

Whose Problem?The Patient The American Diabetes association found that "diabetics hospitalized for non-critical illnesses who develop hypoglycemia during hospitalization have an increased likelihood of remaining hospitalized longer and a greater risk of mortality both during and after hospitalization."(Turchin et al) Hypoglycemia can lead to many serious problems and complications. According to Dr. Koch, Canadian Family Physician, these serious conditions include, "impaired cognitive function and unmasking of an epileptic focus, silent myocardial infarction, angina, and progression of retinopathy."(www.pubmedcentral.com)

Whose Problem?Loved Ones : 

Whose Problem?Loved Ones Families of patients who were injured or died due to medical error or "never events" feel a sense of guilt when these incidents occur. According to research performed by Dr. Delbanco and Dr. Bell, family members "fear further harm, including retribution from health care workers, if they express their feelings or even ask about mistakes they perceive." Families often feel guilty and a sense of failure because they cant be with their loved ones 24 hours a day. They feel as if they should have been with the patient(Delbanco and Bell, nejm). Families can be awarded compensation for previous and ongoing medical costs, and for pain and suffering due to medical professionals' medical errors.

Whose Problem?Healthcare Providers : 

Whose Problem?Healthcare Providers Professional healthcare providers who are involved in a "never event" are subject to having their medical license suspended, and even loss of hospital privileges. (www.healthcentral.com) A hospital or surgeon can be sued for medical malpractice, which would result in a substantial increase in insurance premiums. Doctors can also lose their licenses in their practicing state. (www.insure.com)

Whose Problem?Healthcare Institutions : 

Whose Problem?Healthcare Institutions Hospital acquired hypoglycemia not only affects the patients/families, but it significantly affect hospitals financially. It is estimated that it costs a hospital over $40,000 to care for a patient with hypoglycemia.(www.hosira.com) Besides the increased costs of care, hospitals are also facing significant economic effects as a result of patients acquiring hypoglycemia while in their care. Hospitals are now having to cover the cost of care because Medicad and Medicare are no longer reimbursing hospitals for the cost. The Centers for Medicare and Medicad Services (CMS) decided in October 2008 that they will no longer reimburse hospitals for the costs of "Never Events". CMS expects to save $190 million over the next 5 years by refusing to cover these costs." The hospitals can also lose certification of the hospital,which means "the hospital will no longer receive reimbursement for Medicare or Medicaid patients" which can cause a large loss in revenue and even complete closure of the hospital. "A hospital can lose its accreditation from the Joint Commission, the accrediting agency that certifies and inspects health care organizations in the United States"(www.insure.com)

Whose Problem?Healthcare Institutions : 

Whose Problem?Healthcare Institutions Insurers are saving money by are no longer paying for major medical mistakes that appear on the list of never events. They will no longer cover these events because they are not supposed to ever happen if patients are cared for properly. (www.insure.com)

Hypoglycemia, the Culprit? : 

Hypoglycemia, the Culprit? "Although the mortality rate among hospitalized patients with hypoglycemia has been shown to be 22.2 to 27% in series that included patients with diabetes, some investigators have shown that hypoglycemia is not an independent predictor of mortality. Outside the critical care setting, the comparative risks of hyperglycemia and hypoglycemia and the relationship of hospital hypoglycemia to intensification of glycemic control have not been determined." http://aace.metapress.com/app/home/contribution.asp?referrer=parent&backto=issue,15,16;journal,45,103;homemainpublications,1,1; The issue is compounded by observing that “diabetes related cardiovascular events, including stroke and heart disease, are leading reasons for hospitalization. Many of these patients are at risk for hypoglycemia because of their critical health status and altered mental status.” (Tomsky, 2005). In particular for Type 1 diabetes patients, “a typical feature of the dead in bed syndrome is the unexpected death at night suggesting severe hypoglycemic episodes could be a pathogenic trigger for these sudden deaths.” (2005). It is difficult to determine the culprit because the condition is rare and because of “difficulty identifying low blood glucose levels at post-mortem” (Tomsky 2005). Tomky, D. (2005). Detection, Prevention, and Treatment of Hypoglycemia in the Hospital. Diabetes Spectrum, 18, 39-44.

A Vigilant Solution : 

A Vigilant Solution The Institute of Medicine defines medical errors “as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”(ANA, 1999). Nurses must excel in assigning meaning to "what is" actually happening with a patient is an essential facet of nursing practice, (and) the ability to anticipate and observe for "what might happen" is another critical component of professional vigilance.” 2005 Online Journal of Issues in Nursing Serptember 3, 2005, Vol 10 - 2005 Vigilance: The Essence of Nursing Geralyn Meyer, PhD, RN Mary Ann Lavin, ScD, RN, FAAN