A Systems Approach to Reducing Errors in Insulin Therapy in the Inpatient Setting

doi:10.4158/EP.10.S2.100

Endocrine Practice

Volume 10, Supplement 2, March 2004, Pages 100-108

https://doi.org/10.4158/EP.10.S2.100 Get rights and content

ABSTRACT

Objective

To highlight the importance of insulin-related medical errors in causing poor outcomes in a hospital setting and to propose a systems approach for improvement.

Results

Evidence reported in the medical literature has identified insulin therapy errors as a large and clinically important problem. Insulin has been labeled as one of the top five “high-risk medications” in the inpatient setting. Although insulin therapy can be lifesaving in the hospital setting, it can be life-threatening if used inappropriately. Widespread major systemic problems, such as heavy patient loads for physicians and nurses, absence of backup checks in critical areas, defective communication and coordination, illegible handwriting, and unawareness of the importance of blood glucose control, create obstacles to appropriate and safe care of patients receiving insulin in the hospital. With thorough analysis of the setting, additional training, collective establishment of goals focused on patient safety, insertion of backup checks in areas susceptible to errors, encouragement of sharing of key clinical information, and, where possible, implementation of electronic medical records, systemic and knowledge-based problems will be minimized and outcomes will improve in insulin-treated hospitalized patients.

Conclusion

Analysis and redesign of systems to develop a “culture of safety” will ultimately reduce insulin-related medical errors, provide a safe inpatient environment, and yield better outcomes. (Endocr Pract. 2004;10[Suppl 2]:100-108)

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 Ergonomics
Citation 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.
Insulin is a high-risk medicine that has been implicated in serious adverse events for hospital inpatients, including medication-error related deaths. Most insulin errors occur during administration, and “wrong dose” is the most common type. A paper-based subcutaneous insulin chart (the “NSIC”) was developed for the Australian Commission on Safety and Quality in Health Care, using a range of human factors methods, with the aim of reducing the opportunity for errors. The present lab-based study empirically assessed whether the NSIC's human factors design translates into improved user-performance in the determination of insulin doses, compared with a pre-existing chart. Forty-one experienced nurses and 48 novice chart-users completed 60 experimental trials (30 per chart), in which they determined doses to administer to patients. Both groups determined insulin doses faster, and made fewer dose errors, when using the NSIC. These results support the utility of the usability heuristics employed in developing the chart.
Evaluating the Impact of Inadequate Meal Consumption on Insulin-Related Hypoglycemia in Hospitalized Patients
2021, Endocrine Practice
Meal intake is sometimes reduced in hospitalized patients. Meal-time insulin administration can cause hypoglycemia when a meal is not consumed. Inpatient providers may avoid ordering meal-time insulin due to hypoglycemia concerns, which can result in hyperglycemia. The frequency of reduced meal intake in hospitalized patients remains inadequately determined. This quality improvement project evaluates the percentage of meals consumed by hospitalized patients with insulin orders and the resulting risk of postmeal hypoglycemia (blood glucose [BG] <70 mg/dL, <3.9 mmol/L).
This was a retrospective quality improvement project evaluating patients with any subcutaneous insulin orders hospitalized at a regional academic medical center between 2015 and 2017. BG, laboratory values, point of care, insulin administration, diet orders, and percentage of meal consumed documented by registered nurses were abstracted from electronic health records.
Meal consumption ≥50% was observed for 85% of meals with insulin orders, and bedside registered nurses were accurate at estimating this percentage. Age ≥65 years was a risk factor for reduced meal consumption (21% of meals 0%-49% consumed, P < .05 vs age < 65 years [12%]). Receiving meal-time insulin and then consuming only 0% to 49% of a meal (defined here as a mismatch) was not rare (6% of meals) and increased postmeal hypoglycemia risk. However, the attributable risk of postmeal hypoglycemia due to this mismatch was low (4 events per 1000) in patients with premeal BG between 70 and 180 mg/dL.
This project demonstrates that hospitalized patients treated with subcutaneous insulin have a low attributable risk of postmeal hypoglycemia related to inadequate meal intake.
Prescribing Insulin for People With Diabetes in Secondary Care: Recommendations and Future Direction
2019, Encyclopedia of Pharmacy Practice and Clinical Pharmacy: Volumes 1-3
This chapter focuses on the safe use of insulin for people with diabetes in secondary care settings. The risks associated with insulin use in hospitals are outlined, and the types and causes of medication errors associated with insulin are discussed. A variety of interventions to improve insulin prescribing are presented, along with a summary of the recommendations for the safe prescribing of insulin in hospital. The opportunities for pharmacist intervention to promote insulin safety are highlighted and illustrated with case studies from a teaching hospital in the United Kingdom.
Incidence of Intravenous Medication Errors in a Chinese Hospital
2015, Value in Health Regional Issues
The purpose of this study was to explore intravenous (IV) medication errors in a Chinese hospital. The specific objectives were to 1) explore and measure the frequency of IV medication errors by direct observation and identify clues to their causes in Chinese hospital inpatient wards and 2) identify the clinical importance of the errors and find the potential risks in the preparation and administration processes of IV medications.
A prospective study was conducted by using the direct observational method to describe IV medication errors on two general surgery patient wards in a large teaching hospital in Beijing, China. A trained observer accompanied nurses during IV preparation rounds to detect medication errors. The difference in mean error rates between total parenteral nutrition (TPN) and non-TPN medications was tested by using the Mann-Whitney U test.
A final total of 589 ordered IV doses plus 4 unordered IV doses as prepared and administered to the patients was observed from August 3, 2010, to August 13, 2010. The overall error rate detected on the study ward was 12.8%. The most frequent errors by category were wrong dose (5.4%), wrong time (3.7%), omission (2.7%), unordered dose (0.7%), and extra dose (0.3%). Excluding wrong time errors, the error rate was 9.1%. Non-TPN medications had significantly higher error rates than did TPN medications including wrong time errors (P = 0.0162).
A typical inpatient in a Chinese hospital was subject to about one IV error every day. Pharmacists had a very limited role in ensuring the accuracy of IV medication preparation and administration processes.
Review of medication errors in a mother-child University Hospital Center
2014, Pharmacien Hospitalier et Clinicien
Insulin is used for the treatment of diabetes since at least one century. Taking into account this high amount of clinical experience, the computerization of the drug use process, the creation of clinical decision tools and robotization, it is surprising that insulin is still considered a high risk medication.
Descriptive and retrospective study. The main objective was to describe incidents and accidents that occurred with insulin in a mother-child University Hospital Center. Preventive and corrective measures are discussed.
A total of 94 incidents and accidents that occurred with insulin were identified in the incidents and accidents registry of our center, between November 9^th 2010 and November 8^th, 2012. Insulin-related events represented 1.5% (94/6242) of the total number of events that involved at least one medication. Almost all (95% – 89/94) of events were accidents, but no accident caused permanent consequences to the patient.
Preliminary actions were identified as necessary in order to improve the management of insulin use in our center.
L’insuline est utilisée dans le traitement du diabète depuis près d’un siècle. Avec autant de recul clinique, l’informatisation du circuit du médicament, la création d’outils d’aide à la décision et la robotisation, il est étonnant de constater qu’elle fait toujours partie des médicaments à risque élevé d’incidents et d’accidents.
Il s’agit d’une étude descriptive rétrospective. L’objectif principal est de décrire les incidents et accidents médicamenteux relatifs à l’insuline et de discuter de mesures préventives et correctrices. L’étude est réalisée dans un centre hospitalier universitaire mère-enfant.
Un total de 94 incidents et accidents portant sur l’insuline a été identifié à partir du registre des incidents et accidents du 9 novembre 2010 au 8 novembre 2012. Les événements relatifs à l’insuline représentaient 1,5 % (94/6242) de l’ensemble des événements comportant au moins un médicament. Près de 95 % (89/94) des événements étaient des accidents, mais aucun des accidents ne comportait de conséquences permanentes pour le patient.
Dans le cadre de notre réflexion sur les meilleures pratiques du circuit du médicament et de l’analyse de ces incidents/accidents, nous avons identifié une liste d’actions préliminaires nécessaires afin de mieux encadrer l’utilisation de l’insuline au sein de notre établissement.
Impact of a clinical decision support system for high-alert medications on the prevention of prescription errors
2014, International Journal of Medical Informatics
To evaluate the impact of a high-alert medication clinical decision support system called HARMLESS on point-of-order entry errors in a tertiary hospital.
HARMLESS was designed to provide three kinds of interventions for five high-alert medications: clinical knowledge support, pop-ups for erroneous orders that block the order or provide a warning, and order recommendations. The impact of this program on prescription order was evaluated by comparing the orders in 6 month periods before and after implementing the program, by analyzing the intervention log data, and by checking for order pattern changes.
During the entire evaluation period, there were 357,417 orders and 5233 logs. After HARMLESS deployment, orders that omitted dilution fluids and exceeded the maximum dose dropped from 12,878 and 214 cases to 0 and 9 cases, respectively. The latter nine cases were unexpected, but after the responsible programming error was corrected, there were no further such cases. If all blocking interventions were seen as errors that were prevented, this meant that 4137 errors (3584 of which were ‘dilution fluid omitted’ errors) were prevented over the 6-month post-deployment period. There were some unexpected order pattern changes after deployment and several unexpected errors emerged, including intramuscular or intravenous push orders for potassium chloride (although a case review revealed that the drug was not actually administered via these methods) and an increase in pro re nata (PRN; administer when required) orders for most drugs.
HARMLESS effectively implemented blocking interventions but was associated with the emergence of unexpected errors. After a program is deployed, it must be monitored and subjected to data analysis to fix bugs and prevent the emergence of new error types.

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ACE Inpatient Diabetes and Metabolic Control Consensus ConferenceA Systems Approach to Reducing Errors in Insulin Therapy in the Inpatient Setting

ABSTRACT

Objective

Results

Conclusion

Section snippets

INTRODUCTION

ANALYSIS OF MEDICAL ERRORS

TYPES OF MEDICAL ERRORS

SYSTEMS APPROACHES TO IMPROVED INPATIENT INSULIN THERAPY

CONCLUSION

J Am Coll Cardiol.

To Err Is Human: Building a Safer Health System

Systems analysis of adverse drug events

JAMA.

“High-alert” medications and patient safety

Int J Qual Health Care.

Effect of intensive treatment of diabetes on the risk of death or renal failure in NIDDM and IDDM

Diabetes Care.

Provider error is an important cause of poor outcomes in diabetes care [abstract]

Diabetes

What practices will most improve safety? Evidence-based medicine meets patient safety

JAMA.

Keeping Patients Safe: Transforming the Work Environment of Nurses

Human Error

Making Health Care Safer: A Critical Analysis of Patient Safety Practices

Glucose control and mortality in critically ill patients

JAMA.

ACE Inpatient Diabetes and Metabolic Control Consensus Conference
A Systems Approach to Reducing Errors in Insulin Therapy in the Inpatient Setting