QUALITY IN THE
FIRST PERSON
A Perfect Corrective Action
ot long ago, my 15-year-old
N 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 condi-
tion 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 blood-
stream and the blood becomes
increasingly acidic. If untreated, it can
become fatal in a matter of days.
We were aware her sugar levels had
FIGURE 1 Fishbone Diagram
Man
(person)
Underlying infection
Insulin schedule
Insulin dosage
Dietary restrictions Expired test strips
Blood-glucose meter
Injector pen malfunction
Syringe malfunction
Machines
76 I AUGUST 2006 I www.asq.org
by Jim Franklin
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
Fishbone diagrams
can be used every
day—even to help a
loved one.
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 hospi-
tal, we asked the specialists for possi-
ble causes. They offered two possible
explanations: not enough insulin or too
much sugar. She either must be skip-
ping insulin injections or cheating on
her dietary restrictions. We knew nei-
ther 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 rec-
ommended a change in the insulin
dosage but still had no new ideas—
Materials
Incorrect insulin
Expired insulin
Using pen incorrectly
Drawing insulin from vial
Using syringe incorrectly
Methods
outside of our daughter’s cheating—
as to how this had happened.
I guess I have been a quality assur-
ance manager for too long. I know my
daughter well enough to know she
takes great pride in managing her dia-
betes 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 deter-
mine the cause, I used a standard fish-
bone 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:
1. Man (person): Was there an
underlying condition that caused
the illness? Was she cheating on
dosages or diet?
2. Materials: Were the insulin and
blood testing strips OK?
3. Machine: Was any of the testing
or injection equipment malfunc-
tioning?
4. 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 meth-
ods, my daughter uses two to inject
insulin. The first is by using a syringe—
withdrawing the required amount of
Unstable
blood glucose
readings
 Please
insulin from a vial and injecting it REFERENCE
comment
under the skin. My wife and I had seen 1. American Diabetes Assn., www.diabetes.
org/about-diabetes.jsp. If you would like to comment on
her do this numerous times and knew
it was not the problem. this article, please post your remarks
JIM FRANKLIN is a quality management sys-
The second method is by using an tem training manager for Samuel Son & Co. in on the Quality Progress Discussion
injector pen. She generally uses Hamilton, Ontario. He has an engineering tech- Board at www.asq.org, or e-mail
syringes in the morning and the injec- nology diploma in metallurgy from Mohawk them to editor@asq.org.
tor pen for the balance of the day. With College in Hamilton. Franklin is a member of
this method, the insulin is contained in ASQ and a certified quality manager.
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 manufac-
turer’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 every-
thing. 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 proper-
ly 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 fail-
ure can occur. Using a fishbone analy-
sis ensures this. In my daughter ’s
case, this method revealed the single
root cause. It turned out to be the per-
fect 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.

QUALITY PROGRESS I AUGUST 2006 I 77