Utilisation de l’insuline en établissement de santé universitaire mère-enfant : Une analyse des modes de défaillance au moyen d’un diagramme d’Ishikawa
Bibliographic record
Abstract
Resume Objectif : Determiner les modes de defaillance lies a l’utilisation de l’insuline dans un centre hospitalier universitaire mereenfant. Description de la problematique : L’insuline est un medicament comportant un risque eleve d’erreurs medicamenteuses. Une revue documentaire a ete realisee afin de specifier les risques inherents a l’utilisation de l’insuline dans le circuit du medicament. Les modes de defaillance ont ete determines par consensus et presentes sous forme de diagramme d’Ishikawa. Huit etapes cles du circuit du medicament ont ete retenues pour la structure du diagramme d’Ishikawa. Au total, 70 modes de defaillance ont ete releves. Apres consultation et discussion, l’equipe de recherche a retenu 49 modes de defaillance. Discussion : Plusieurs caracteristiques de l’insuline mettent en evidence ces modes de defaillance, notamment le fait que l’insuline soit disponible en plusieurs denominations communes et en plusieurs formats, qu’elle soit administree par plusieurs voies, qu’elle requiere plusieurs dispositifs d’administration et de suivi et qu’elle soit administree selon plusieurs horaires. Conclusion : Cette etude descriptive sous forme de diagramme d’Ishikawa met en evidence 49 modes de defaillance lies a l’utillisation de l’insuline. En suivi a cette analyse, une douzaine d’actions concretes ont ete determinees afin de reduire les risques inherents au circuit du medicament. Abstract Objective: To identify the failure modes in the use of insulin at a university teaching mother-child hospital. Description of problem: Insulin is associated with a high risk of medication errors. A literature review was conducted to identify, in the medication circuit, the risks inherent in the use of insulin. The failure modes were determined by consensus and presented in the form of an Ishikawa diagram. Eight key steps in the medication circuit were used as the diagram’s structure. In all, 70 failure modes were identified. After consultation and discussion, the research team selected 49 of them. Discussion: Several characteristics of insulin explain these failure modes, such as the fact that it is available under several generic names and in several formats, that there are several routes of insulin administration, that it requires several administration and monitoring devices, and that there are various insulin administration schedules. Conclusion: This descriptive study in the form of an Ishikawa diagram reveals 49 failure modes in the use of insulin. As a follow-up to this analysis, a dozen concrete actions were identified for reducing the risks inherent in the medication circuit. Keywords: Failure mode analysis, insulin, Ishikawa diagram
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.006 | 0.019 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.003 | 0.003 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.013 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".