Improving systems through the use of improvement and safety science: A case study in pain pump and patient transfer processes

Shea Polancich, Terri Poe, Linda Moneyham


Introduction: Using a pain pump or patient controlled analgesia (PCA) has been shown to be an effective method of pain control. The goal for the bedside nurse is to maintain patient safety while allowing patient autonomy for pain control. Healthcare organizations define established processes, protocols and standards that are relevant to the safe performance of actionable tasks. This case study describes an opportunity for improvement in process variation associated with the use of pain pumps/PCAs and patient transport.

Methods: In this case study, a perceived process variation was identified in the transport of hospitalized inpatients to different locations with pain pumps. A systematic approach to mitigating process variation was implemented using an inter-professional team approach including the use of a team charter, defined methodological framework incorporating the Model for Improvement, Plan-Do-Study-Act cycle, microsystem analysis, indirect event review, and evidence appraisal.

Results: Process variation in the management of patients with a pain pump being transported throughout the healthcare organization was the result of system gaps in communicating and managing organizational policies and procedures. The results of the analysis of the pain pump transfer project highlighted the following: system-based improvement, leadership accountability, and education-practice partnerships.

Conclusions: Managing the transport of patients with a pain pump within a healthcare organization is a process that should be standardized, communicated and well understood by all providers. From a broader perspective, this case study highlighted an organizational need to develop a standardized process for learning from process variation, but also for developing tools and competencies within the organization for this work.


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Journal of Nursing Education and Practice

ISSN 1925-4040 (Print)   ISSN 1925-4059 (Online)

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