QUALITY IN THE FIRST PERSON
A Perfect Corrective Action
by Jim Franklin
Not long ago, my 15-year-old daughter, who has type one diabetes, became severely ill and needed to go to the emergency room.
Type one diabetes—which accounts for 5 to 10% of all diabetes cases1—is a condition in which the pancreas stops producing insulin, a chemical the body requires to use sugar as food. People with type one diabetes must keep a careful watch on their diets and regularly inject themselves with insulin to remain healthy.
They also must monitor their blood-glucose levels—if there is too little insulin or too much sugar in the body, the unprocessed sugar stays in the bloodstream and shows up as a high blood glucose reading. Sick days can be difficult for a person with diabetes.
Upon my daughter’ admission to the hospital, we learned her nausea was in fact caused by elevated sugar levels and she was in the early stages of diabetic keto-acidosis. This condition results when the body is unable to process sugar due to lack of insulin and attacks its own fat cells in an attempt to feed itself.
The waste materials (ketones) from this process build up in the bloodstream and the blood becomes increasingly acidic. If untreated, it can become fatal in a matter of days.
We were aware her sugar levels had been difficult to maintain over the last couple months but were at a loss as to why. The only trend we had noticed through plotting her blood glucose readings was that they often would be fine in the morning but elevate over the course of the day. Any corrections our daughter was making to the insulin doses to remedy this seemed to have no effect.
Once she had stabilized in the hospital, we asked the specialists for possible causes. They offered two possible explanations: not enough insulin or too much sugar. She either must be skipping insulin injections or cheating on her dietary restrictions. We knew neither was the case.
After returning home with few answers, we were dismayed when within 10 hours her blood sugar had gone from being in the acceptable range to more than 2.5 times that with no explanation. We contacted one of the specialists at 3:00 a.m., and he recommended a change in the insulin dosage but still had no new ideas—outside of our daughter’s cheating—as to how this had happened.
I guess I have been a quality assurance manager for too long. I know my daughter well enough to know she takes great pride in managing her diabetes on her own and would neither skip injections nor cheat on her diet. I looked at the chart we had main-tained to try to make some sense of what was happening. To help determine the cause, I used a standard fishbone analysis. This tool organizes what may be a long list of causes into four major areas—man, materials, machine and method.
The four areas in this case were:
- Man (person): Was there an underlying condition that caused the illness? Was she cheating on dosages or diet?
- Materials: Were the insulin and blood testing strips OK?
- Machine: Was any of the testing or injection equipment malfunctioning?
- Method: Was she using the equipment correctly?
Figure 1 shows the resulting fishbone diagram. Our investigation and records showed none of the causes associated with the man, materials and machine categories were present. As for methods, my daughter uses two to inject insulin. The first is by using a syringe—withdrawing the required amount of insulin from a vial and injecting it under the skin. My wife and I had seen her do this numerous times and knew it was not the problem.
The second method is by using an injector pen. She generally uses syringes in the morning and the injector pen for the balance of the day. With this method, the insulin is contained in a cartridge in the pen. She turns a dial to set the dosage, causing the end of the pen, or plunger, to move outward. Depressing the plunger injects the insulin through the needle into the skin and spins the dial back to the zero position.
I asked my daughter to show me how she was using the injector pen. Her method seemed OK to me. However, I looked up the manufacturer’s manual on the internet, and it showed a different method. I got the pen and, using the manufacturer’s instructions, squirted insulin out of the needle. I then used it the way that she had been, and nothing came out.
In looking at the chart we had put together, this cause explained everything. I spoke to my daughter about it later that morning. When she used the pen, she dialed in the correct dosage, but instead of depressing the plunger to deliver the insulin, she was just turning the dial back to zero.
This caused the plunger to depress, making it appear as though insulin had been injected when it really had not. She had changed her method because it was difficult to use the pen properly when injecting larger doses. Since she began using the pen properly again, she has been able to easily manage her blood glucose levels.
When determining the root cause of a problem, whether inside or outside our work environment, it is important to investigate all areas in which failure can occur. Using a fishbone analysis ensures this. In my daughter’s case, this method revealed the single root cause. It turned out to be the perfect corrective action in that it explained both the lack of control as well as the daily trend of her sugar rising from morning to evening.
It is rare to have a corrective action that answers everything and even more gratifying when it concerns the health of someone you love.
- American Diabetes Assn., www.diabetes.org/about-diabetes.jsp.
JIM FRANKLIN is a quality management system training manager for Samuel Son & Co. in Hamilton, Ontario. He has an engineering technology diploma in metallurgy from Mohawk College in Hamilton. Franklin is a member of ASQ and a certified quality manager.