Insulin Administration Errors Research Articles

Assessing outcomes of intravenous insulin therapy in non-intensive care patients

ABSTRACT Objectives The aim of this study was to compare outcomes of using intravenous insulin infusion (IVII) therapy for managing hyperglycemia in a non-intensive care unit (ICU) versus an ICU setting. Methods We conducted a retrospective analysis on patients who received IVII for hyperglycemia. The analysis compared variables associated with hypoglycemic events while on IVII, and point-of-care blood glucose control and insulin regimens at discharge. Insulin administration errors occurring on IVII were determined. Results Between November 2020 and August 2022, 881 patients received 1,106 IVIIs (780 in ICU and 326 non-ICU). A cumulative 468 days were spent on IVII in the non-ICU setting and 1564 in the ICU (total 2,032 days). The frequency of hypoglycemia on IVII was higher when provided in the non-ICU vs ICU (1.4% vs 0.7%), p < 0.01). Non-ICU patients had significantly higher average blood glucose during the last 24 h of the hospital stay (185 mg/dL vs 160 mg/dL, non-ICU vs. ICU, Pp < 0.01) and were more likely discharged with basal-bolus insulin therapy (p < 0.01). After adjusting for other variables, the probability of having hypoglycemia (OR 2.35; 95% CI 1.62–3.42; p < 0.001) was higher for the non-ICU cohort. In addition, patients who received IVII in the non-ICU settings had mean glucose levels nearly 26 mg/dL higher (95% CI 19.40–32.9, p < 0.001) at discharge vs. ICU. Seven cases of insulin errors were reported while on IVII in the non-ICU settings, compared to one in the ICU. Conclusions A large number (468) of ICU days were avoided by providing IVII in the non-ICU setting. Of the more than 400 days of IVII therapy provided in the non-ICU, only 7 medication errors occurred. Further studies are needed to optimize IVII strategy for non-ICU patients.

100 Years After the Discovery of Insulin and in the Era of New Generations of Insulins, What Do Our Patients and Care Staff Know About Insulin Therapy?

According to "Never Events", insulin administration errors are serious preventable adverse events that should not have occurred if adequate preventive measures had been implemented. The event "insulin administration error" is on the ANSM list published in 2012. The National Health Service's (NHS) "Never Events insulin" has developed a module on insulin therapy management entitled "Preventing insulin-related medication errors". Proper use and knowledge of insulin management can prevent these events. Our study presents the results of a survey designed to assess both the knowledge of healthcare personnel and a group of diabetic patients in the Souss Massa region of Morocco. Our survey was an opportunity to re-educate our patients and review the knowledge of a group of staff interviewed, underlines the important deficit in knowledge and practice of nursing staff and insulin-treated patients, suggests that urgent intervention should be considered, particularly with young nursing staff, and also to review the therapeutic education of insulin-treated diabetics in order to improve their knowledge and better prepare them for the advent of new generations of insulin.

Creating sustained and positive changes to patient safety: reducing insulin administration errors in a district nursing service.

Administering insulin in a patient's own home is perceived as a simple nursing intervention, and one that is regularly delegated to newly qualified staff, agency and bank staff. However, without robust processes and clear, easy-to-follow nursing documentation in place, a simple nursing intervention can easily lead to an avoidable medication error and patient safety incident. This article describes the steps one trust has taken to combat insulin administration incidents. The article describes the use of a Plan, Do, Study, Act (PDSA) cycle to help test changes and roll out sustainable transformation. It describes some of the challenges faced, alongside the solutions tested and embedded into practice.

Reducing potential errors associated with insulin administration: An integrative review.

Around one-third of medication errors resulting in death within 48 h involve insulin therapy. Despite a growing number of interventional strategies that have been published over the past decade, it remains unclear which of these interventions is effective in reducing insulin errors. Therefore, the study aimed to synthesize interventions to reduce the frequency of insulin errors in either home or health care settings. This integrative review was conducted based on Whittemore and Knafl's four steps, which includes problem identification, literature search, data analysisand presentation. Six databases including Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, PsychInfoand Cochrane were searched from January 2010 through July 2021. The level of evidence quality was assessed according to the Johns Hopkins Nursing Evidence-Based Practice grading scale. Sixteen studies meeting inclusion criteria were reviewed. The results provide strong support for teaching patients how to use automated bolus calculators and educating patients to self-administer insulin to prevent insulin errors in the home setting. Computerized protocols, educationand double-checking procedures were also found to be effective strategies for minimizing insulin errors in healthcare settings. While the strategies might be effective in reducing insulin administration errors in the home settings, computerized protocols, continuing educationand the manual validation of insulin products appear to be the most effective strategies for reducing such insulin errors in healthcare settings. Understanding these findings may help clinicians and patients to decrease the number of insulin errors administration.

Use of Computer Vision to Identify the Frequency and Magnitude of Insulin Syringe Preparation Errors.

No current technology exists to ensure the dose of insulin administered in hospitals matches the physician order. Assess the feasibility of using computer vision to identify insulin syringe preparation errors. Twenty-two nurses prepared 50 insulin doses (n=1100) each. A computer vision device (CVD) measured the volume drawn up and identified air present. Syringes identified as inaccurate by the CVD were confirmed by two observers, and a random sample of 100 syringes identified as accurate was validated by two independent observers. Ten syringes (1.0%) had the wrong volume prepared, and 68 syringes (6.5%) contained air sufficient to meet the definition of inaccuracy. All errors were confirmed by two independent observers. CVDs could reduce insulin administration errors in hospitalized patients.

Preventing insulin administration errors with multidose vials.

Preventing insulin administration errors with multidose vials.

Reducing Insulin Administration Errors in Inpatients from a Nursing Perspective: A Literature Review

It is widely agreed that medication error can not only cause financial, psychological and emotional stress to patients, healthcare professionals, and healthcare providers, but also has the potential to cause severe physical injury and possible death to patients [1]. Over the past century there has been a dramatic increase in researching how to prevent medication error in various healthcare settings, among which the topic of medication administration error remains as the most active area [2,3].

2377-PUB: Evaluation of Structure, Documentation, and Treatment Quality of a New Insulin Chart at Departments of Internal Medicine

Introduction: Insulin charts are the main tool for multidisciplinary documentation of diabetes therapy in the hospital setting. Due to a high heterogeneity of 20 different insulin charts at a tertiary center, a new standardized paper-based insulin chart was developed and implemented at the Departments of Internal Medicine. Methods: A before-after comparison was performed to evaluate structure, documentation, and treatment quality of a new insulin chart compared to old insulin charts. Structure quality of blank insulin charts was assessed by using questionnaires regarding subjective perception of health care professionals (n=237). To assess documentation and treatment quality a retrospective evaluation of 108 old and 100 new filled-in insulin charts of inpatients receiving insulin therapy by using predefined quality parameters was conducted. Results: Patient characteristics from old and new insulin charts were comparable regarding sex (old: 47% vs. new: 42% female), age (71±11 vs. 71±12 years), diabetes type (75% vs. 87% type 2) and HbA1c (62±14 vs. 67±21 mmol/mol). The primary endpoint, the percentage of insulin charts with insulin administration errors, was with 5% significantly better on new insulin charts compared to 77% on old insulin charts (p&amp;lt;0.001). Insulin prescription errors occurred more often on old insulin charts (100% vs. 42%), whereas insulin management errors were rare in both groups (10% vs. 8%). Correct patient identification was rather given on new insulin charts (78% vs. 90%). Both groups had an average of 4±2 good diabetes days. Structure of the new insulin chart was assessed to be more clearly arranged, to give better transparency and to have more space for documentation. Conclusion: Improvements in structure, documentation, and treatment quality were achieved through implementation of the new insulin chart. However, as some errors still occur, further potential to enhance diabetes inpatient care should be considered. Disclosure J. Kopanz: None. K.M. Lichtenegger: None. G. Sendlhofer: None. B. Semlitsch: None. R. Riedl: None. T.R. Pieber: Advisory Panel; Self; ADOCIA, Arecor Limited, AstraZeneca, Novo Nordisk A/S, Sanofi. Speaker's Bureau; Self; Novo Nordisk A/S. C. Tax: None. G. Brunner: None. J. Plank: None.

Assessing nurses’ knowledge of insulin administration and the impact of the introduction of concentrated insulins.

Insulin is a high-risk medication, and even slight changes in blood levels can lead to serious side effects or can even result in death. Error in administering drugs is one of the main causes of over- or under-dosing, and the recent introduction of concentrated insulins (CI) has increased this risk. We assessed nurses’ knowledge of these CI, their beliefs about the “insulin unit” (IU), and the impact that this knowledge had on the risk of making medication errors. A direct interview survey was conducted in eight departments of medicine and surgery in a university hospital. Sixty-eight nurses and midwives were interviewed. Twenty-six percent of them had already encountered a CI prescription and only 51.5 percent correctly defined the notion of IU. Only 18 percent responded correctly to a practical case of a CI prescription, whilst 35 percent multiplied the dose by two and 24 percent divided it by two. Sixty percent indicated that they regularly use a U-100 graduated insulin syringe to withdraw insulin from the pen. Insulin administration errors related to this misuse, which are very well documented in the literature, are linked to nurses’ lack of knowledge about the true definition of IU. These administration errors have increased with the introduction of concentrated insulins.

Does an Insulin Double-Checking Procedure Improve Patient Safety?

The aim of this study was to examine the effectiveness of a subcutaneous insulin double-checking preparation intervention on insulin administration errors. Insulin accounts for 3.5% of medication-related errors. The Joint Commission and Institute for Safe Medication Practices recommend a 2-nurse double-checking procedure when preparing insulin. This study used a randomized, controlled, nonblinded, intent-to-treat methodology. In total, 266 patients were enrolled, and over 4 weeks of data collection, there were 5238 opportunities for insulin administration. Overall, 3151 insulin administration opportunities had no errors; the double-checking group had more no-error periods than usual care. Of error types, wrong time was predominant, but less prevalent in the double-checking group. Omission errors were uncommon and occurred less in the double-checking group. The subcutaneous insulin double-checking preparation procedure led to less insulin administration errors; however, timing errors were most prevalent and are not resolved with double-checking interventions.

Automated detection of medication administration errors in neonatal intensive care

ObjectiveTo improve neonatal patient safety through automated detection of medication administration errors (MAEs) in high alert medications including narcotics, vasoactive medication, intravenous fluids, parenteral nutrition, and insulin using the electronic health record (EHR); to evaluate rates of MAEs in neonatal care; and to compare the performance of computerized algorithms to traditional incident reporting for error detection. MethodsWe developed novel computerized algorithms to identify MAEs within the EHR of all neonatal patients treated in a level four neonatal intensive care unit (NICU) in 2011 and 2012. We evaluated the rates and types of MAEs identified by the automated algorithms and compared their performance to incident reporting. Performance was evaluated by physician chart review. ResultsIn the combined 2011 and 2012 NICU data sets, the automated algorithms identified MAEs at the following rates: fentanyl, 0.4% (4 errors/1005 fentanyl administration records); morphine, 0.3% (11/4009); dobutamine, 0 (0/10); and milrinone, 0.3% (5/1925). We found higher MAE rates for other vasoactive medications including: dopamine, 11.6% (5/43); epinephrine, 10.0% (289/2890); and vasopressin, 12.8% (54/421). Fluid administration error rates were similar: intravenous fluids, 3.2% (273/8567); parenteral nutrition, 3.2% (649/20124); and lipid administration, 1.3% (203/15227). We also found 13 insulin administration errors with a resulting rate of 2.9% (13/456). MAE rates were higher for medications that were adjusted frequently and fluids administered concurrently. The algorithms identified many previously unidentified errors, demonstrating significantly better sensitivity (82% vs. 5%) and precision (70% vs. 50%) than incident reporting for error recognition. ConclusionsAutomated detection of medication administration errors through the EHR is feasible and performs better than currently used incident reporting systems. Automated algorithms may be useful for real-time error identification and mitigation.

Errors in Preparation and Administration of Insulin in Two Urban Vietnamese Hospitals

Medication errors involving insulin are common, particularly during the administration stage, and may cause severe harm. Little is known about the prevalence of insulin administration errors in hospitals, especially in resource-restricted settings, where the burden of diabetes is growing alarmingly. The aim of this study was to determine the prevalence, type, and potential clinical outcome of errors in preparation and administration of insulin in resource-restricted setting hospitals. This study was conducted on six wards in two urban public hospitals in Vietnam using a direct observation method. Details of insulin preparation and administration were collected by pharmacy students 12 hours per day for 7 consecutive days on each ward. Potential clinical outcome was judged by a panel of four experts using a validated scale. The error rate was 28.8% (95% confidence interval [23.1%, 35.2%], n = 66 out of 229 insulin doses)-all with potentially moderate/severe outcome. Higher error rates were observed for infusion doses than for subcutaneous ones (80.0% vs. 22.5%, p < .01). Incorrect time, incorrect preparation/administration technique, and omissions were mostly encountered. Interventions suitable for resource-restricted settings need to be developed and tested to improve insulin preparation and administration, probably starting with education and providing information, especially infusion doses.

A Learner-Centered Diabetes Management Curriculum

OBJECTIVEDiabetes errors, particularly insulin administration errors, can lead to complications and death in the pediatric inpatient setting. Despite a lecture-format curriculum on diabetes management at our children’s hospital, resident diabetes-related errors persisted. We hypothesized that a multifaceted, learner-centered diabetes curriculum would help reduce pathway errors.RESEARCH DESIGN AND METHODSThe 8-week curricular intervention consisted of 1) an online tutorial addressing residents’ baseline diabetes management knowledge, 2) an interactive diabetes pathway discussion, 3) a learner-initiated diabetes question and answer session, and 4) a case presentation featuring embedded pathway errors for residents to recognize, resolve, and prevent. Errors in the 9 months before the intervention, as identified through an incident reporting system, were compared with those in the 10 months afterward, with errors classified as relating to insulin, communication, intravenous fluids, nutrition, and discharge delay.RESULTSBefore the curricular intervention, resident errors occurred in 28 patients (19.4% of 144 diabetes admissions) over 9 months. After the intervention, resident errors occurred in 11 patients (6.6% of 166 diabetes admissions) over 10 months, representing a statistically significant (P = 0.0007) decrease in patients with errors from before intervention to after intervention. Throughout the study, the errors were distributed into the categories as follows: insulin, 43.8%; communication, 39.6%; intravenous fluids, 14.6%; nutrition, 0%; and discharge delay, 2.1%.CONCLUSIONSAn interactive learner-centered diabetes curriculum for pediatric residents can be effective in reducing inpatient diabetes errors in a tertiary children’s hospital. This educational model promoting proactive learning has implications for decreasing errors across other medical disciplines.

A multifaceted program for improving quality of care in intensive care units

To test the effects of three multifaceted safety programs designed to decrease insulin administration errors, anticoagulant prescription and administration errors, and errors leading to accidental removal of endotracheal tubes and central venous catheters, respectively. Medical errors and adverse events are associated with increased mortality in intensive care patients, indicating an urgent need for prevention programs. Multicenter cluster-randomized study. One medical intensive care unit in a university hospital and two medical-surgical intensive care units in community hospitals belonging to the Outcomerea Study Group. Consecutive patients >18 yrs admitted from January 2007 to January 2008 to the intensive care units. We tested three multifaceted safety programs vs. standard care in random order, each over 2.5 months, after a 1.5-month observation period. Incidence rates of medical errors/1000 patient-days in the multifaceted safety program and standard-care groups were compared using adjusted hierarchical models. In 2117 patients with 15,014 patient-days, 8520 medical errors (567.5/1000 patient-days) were reported, including 1438 adverse events (16.9%, 95.8/1000 patient-days). The insulin multifaceted safety program significantly decreased errors during implementation (risk ratio 0.65; 95% confidence interval [CI] 0.52-0.82; p = .0003) and after implementation (risk ratio 0.51; 95% CI 0.35-0.73; p = .0004). A significant Hawthorne effect was found. The accidental tube/catheter removal multifaceted safety program decreased errors significantly during implementation (odds ratio [OR] 0.34; 95% CI 0.15-0.81; p = .01]) and nonsignificantly after implementation (OR 1.65; 95% CI 0.78-3.48). The anticoagulation multifaceted safety program was not significantly effective (OR 0.64; 95% CI 0.26-1.59) but produced a significant Hawthorne effect. A multifaceted program was effective in preventing insulin errors and accidental tube/catheter removal. Significant Hawthorne effects occurred, emphasizing the need for appropriately designed studies before definitively implementing strategies. clinicaltrials.gov Identifier: NCT00461461.

Inpatient insulin orders: Are patients getting what is prescribed?

In-hospital insulin administration is associated with many medication errors, but the frequency and reasons for insulin administration errors are poorly described. To document types and frequency of errors related to insulin administration, an examination of 4 units was conducted. Using snapshot methodology, 4 non-intensive care unit (ICU) areas (medicine, cardiology, transplant, and surgery) were examined in an observational, prospective manner for 4 weeks. Each patient on insulin on the first day was followed for 7 days. Definitions and error categories were defined prior to data collection. Error types and numbers were collected and quantified on per-day or per-patient basis. A total of 116 patient audit periods covering a total of 378 inpatient hospital days were examined. Inpatient insulin regimens on day 1 included correctional insulin only (51.7% of cases), neutral protamine Hagedorn ([NPH] 12%), and glargine (28.4%). A total of 199 administration errors occurred at a rate of 1.72 errors/patient-period and 0.53 errors/patient day. Missing documentation of doses (15.5% of all patients) and insulin being held without an order (25% of patients) were the most frequently occurring events. Other errors include transcription (7.5%), timing errors (22.7%), and lack of documentation of physician notification of hypoglycemia (12.6%). Errors associated with insulin in the hospital are common and reveal a number of system errors that should be addressed. These data provide a foundation for future performance improvement.

Impact of an Interactive Online Nursing Educational Module on Insulin Errors in Hospitalized Pediatric Patients

OBJECTIVETo determine the effectiveness of an online module for reducing insulin administration errors by nurses caring for hospitalized pediatric patients.RESEARCH DESIGN AND METHODSPediatric nursing staff completed a mandatory online educational module teaching insulin pharmacokinetics and the insulin order form, using diluted insulin and finishing with 15 interactive cases. A chart audit to determine all possible insulin errors of patients receiving insulin was done before and 2–6 months after the educational module.RESULTSAll of the medical center's 283 pediatric nurses successfully completed the educational module. A total of 24 charts were audited in the preintervention phase and 22 in the postintervention phase. The preintervention insulin error rate was 14.8%, reduced to 1.7% (P < 0.001) postintervention. Improvement occurred in correct insulin dosing and type, timing of administration, and timely blood glucose monitoring and documentation.CONCLUSIONSAn interactive online educational module can be an effective strategy for reducing pediatric nurses' insulin administration errors.

Selected Medical Errors in the Intensive Care Unit

Although intensive care units (ICUs) were created for patients with life-threatening illnesses, the ICU environment generates a high risk of iatrogenic events. Identifying medical errors (MEs) that serve as indicators for iatrogenic risk is crucial for purposes of reporting and prevention. We describe the selection of indicator MEs, the incidence of such MEs, and their relationship with mortality. We selected indicator MEs using Delphi techniques. An observational prospective multicenter cohort study of these MEs was conducted from March 27 to April 3, 2006, in 70 ICUs; 16 (23%) centers were audited. Harm from MEs was collected using specific scales. Fourteen types of MEs were selected as indicators; 1,192 MEs were reported for 1,369 patients, and 367 (26.8%) patients experienced at least 1 ME (2.1/1,000 patient-days). The most common MEs were insulin administration errors (185.9/1,000 d of insulin treatment). Of the 1,192 medical errors, 183 (15.4%) in 128 (9.3%) patients were adverse events that were followed by one or more clinical consequences (n = 163) or that required one or more procedures or treatments (n = 58). By multivariable analysis, having two or more adverse events was an independent risk factor for ICU mortality (odds ratio, 3.09; 95% confidence interval, 1.30-7.36; P = 0.039). The impact of medical errors on mortality indicates an urgent need to develop prevention programs. We have planned a study to assess a program based on our results.