ACE Inpatient Diabetes and Metabolic Control Consensus ConferenceA Systems Approach to Reducing Errors in Insulin Therapy in the Inpatient Setting
Section snippets
INTRODUCTION
Although the literature documenting medical errors in diabetes care is sparse, sufficient evidence is available in the published literature to identify insulin therapy errors as a large and clinically important problem. The Institute of Medicine (IOM) report entitled “To Err Is Human” (1) identified medical errors as one of the leading causes of death in the United States. The IOM estimated that 98,000 persons die each year as a result of preventable medical errors. Although the methods used in
ANALYSIS OF MEDICAL ERRORS
During the past 20 years, a gradual paradigm shift has evolved in our understanding of medical errors. Although the current malpractice law focuses on the individual health provider as the focus of accountability (in retrospect) for any injury to the patient, a more modern and scientific analysis points in a different direction. In complex systems, it is apparent that catastrophic errors often have very complicated roots involving multiple individuals. In fact, the design of the system may, in
TYPES OF MEDICAL ERRORS
Most errors never cause injury but are identified and corrected by a member of the health-care team. A recent study in two hospitals for a 6-month period (7) found that nurses were responsible for intercepting 86% of all medication errors made by physicians, pharmacists, and others involved in providing medications for patients. I suspect, however, that the error rate was actually higher—in light of human propensity for brief lapses and slips that are quickly self-corrected—and that the
SYSTEMS APPROACHES TO IMPROVED INPATIENT INSULIN THERAPY
Nurses need more training regarding insulin therapy than they now receive (7). Hospitals and the physicians who staff them should provide nurses with standards for insulin administration that would enable nurses to do their jobs better. Computerized physician order entry should be added, or preprinted, approved, unambiguous standard order sheets for insulin administration should be used. Use of only relatively few order sets for insulin administration will reduce implementation errors.
CONCLUSION
In the hospital setting, insulin therapy can be life-saving, but if it is suboptimally provided or monitored, it may instead be life-threatening. At present, widespread major systemic problems are deterrents to good patient care and often create an unsafe environment for hospitalized patients. Rather than being a problem of a careless physician who unintentionally injures a patient or a nurse who negligently fails to implement clear insulin orders, the most serious problems are almost always
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Cited by (77)
A human factors approach to subcutaneous insulin chart design improves user-performance: An experimental study
2021, Applied ErgonomicsCitation Excerpt :Although the absolute reduction in the incidence of incorrect doses as a percentage of all doses determined by participants was only 2.22%, this figure actually represents a 23.44% reduction in the number of incorrect doses. Reductions of this magnitude are of practical significance given that a single incorrect dose may result in hypoglycaemia or hyperglycaemia (McIver et al., 2009) and, in some cases, this can have disastrous consequences for the patient (ACSQHC, 2017; Cohen et al., 2007; Hellman, 2004). However, given that chart design had a large effect (Cohen, 1992) on response time for novices (d = 2.19) and experienced nurses (d = 0.97) alike, it may be that insulin dose response time was a more sensitive indicator of the usability of the charts in performing this task, and that the inferior usability of the pre-existing chart may have a larger impact on the error rate under real-world conditions.
Prescribing Insulin for People With Diabetes in Secondary Care: Recommendations and Future Direction
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