QI: MEDICATION ERRORS

INSULIN ADMINISTRATION
Spring 2014, N362 Leeah Javier, Tiare Palimoo, Jessica Lafaele, Diane Nichols and Brandi Anastacio
http://www.youtube.com/watch?v=vxrkQOQLSU8

Why should health care professionals be concerned about Insulin Administration?

According to Healthy People 2020, 8 Diabetes

out of 1,000 people age 18-84 are diagnosed with live in Hawaii, with a projection of at least 26% of persons with

The American Diabetes Association states over 113,000 1 out of 3 persons by 2050 Center for Disease Control and Prevention estimates that diabetes require insulin to maintain glucose levels

The Institute for Safe Medication Practice (ISMP) has named Insulin as one of the five HIGH ALERT medications, due to its high risk of causing injury if misused.

During a period of one year, there were a total of 4,764 insulin errors reported to the Medmarx database. Just over 6.5% of these errors caused harm to the patient. Thats 310 people!

Administration Errors can happen quickly and are

A sliding scale order was written for regular insulin "4U" when the patient's blood sugar was 240 - 300 mg/dL, The order was misinterpreted and the patient was given 44 units of NPH (intermediate-acting) insuiin instead of regular (short-acting) insulin. When the error was discovered, the patient was given three cups of juice and transferred to the ICU for close monitoring. 2003

fatal

A dialysis technician inadvertently administered insulin instead of heparin to a patient in the dialysis unit of a hospital. Insulin was kept as floor stock in this unit. The patient suffered fatal neurological damage due to decreased glucose levels. 2003

Hospital Physician orders 8 units of insulin for 57 year old female patient, experiencing complications during rehab. Which is transcribed as 8.0 units. Nurse on rehab unit administers 80 units of insulin. Patient dies due to complications and Hospital, transcriptionist and nurse are sued for $140 Million. New York, 2013

ERRORS CAN HAPPEN AT ANYTIME

Phase Prescribing Transcribing Error Incorrect dosage/irrational insulin orders Incorrect use of medical terms Incorrect transcription of verbal or telephone Orders Use u instead of units Use of preceding and trailing zero Transcription of an incorrect dose Failure to double-check insulin products (i.e., Preadministration) Look-alike containers Unsecure and/or non-segregated storage in patient are areas and/or pharmacy areas Administration of incorrect doses Incorrect use of insulin pens Name confusion Relationship of insulin administration to nutrition

Dispensing and storage

Administering

Monitoring

Failure to appropriately monitor for insulin effects and adjust dose accordingly

ROOT CAUSE ANALYSIS

Widely used approach in improving patient safety. Analyzes serious adverse events Identifies underlying problems associated with the the issue

Identify both active errors and latent errors

Analyze sequence of events leading to the error

Ultimate goal is prevention of future harm

ACTION STEPS: PLAN

Goal:
To reduce insulin administration errors

Insulin Administration Errors

9 8 7 6 5 4 3 2 1 0 Unit 1 Unit 2 January February Unit 3 March Unit 4

Preferred Outcomes:
Errors related to administration will decrease by at least 50%. This will be monitored through a reporting system and addressed monthly, with the use of a bar chart, pie chart and flow chart.

Implementations to reach goal:

Promoting a Culture of Safety Provide Education to Staff and Increase Awareness

ACTION STEPS: DO
WITH RECOMMENDATIONS

Promote a Culture of Safety

- Clear communication between all healthcare personnel.

- Store insulin and administration devices in a secure fashion and segregated from other medications. - Ensure insulin use is linked directly to patients nutrition status. - Implement a double check system (two nurses) during preparation of insulin. - The 5 Rights of Medication Administration: Right Patient, Right Medication, Right Dose, Right Route, and Right Time.

Educate All Staff

- Provide mandatory training before administrating insulin pen devices. - Prepare chart that lists all insulin products used in the facility. - Staff members should receive clear instructions about how to proceed if they encounter problems, and real-time support should be accessible at all times. - Provide ongoing education about insulin products and methods of delivery.

NURSING PROCESS FOCUS TO PROMOTE CHANGE

Assess: Completeness of order Appropriateness of dose Timing of doses and meals An independent double check Evaluate patient for S/S of hypo/hyperglycemia Double check the MAR Intervene: Never use intravenous syringes to give insulin Dont use an IV syringe to measure insulin for IV infusion Always use the term unit write it out in full Mix and measure according to policy (correct size syringes), have another nurse double check Take special precautions with look alike meds and vials Evaluate: Assess patients response to insulin and any adverse reactions

Obtain Blood glucose level

Pay special attention patients at risk for hyperglycemia & hypoglycemia Report Errors and Near Misses to QI team

ACTION STEPS: CHECK AND ACT

Begin by conducting staff meetings regarding plan and implementing changes on one specific clinical area or unit within the facility and assign a Quality Improvement Team Member to collect data.

Types of Data to Collect & How:

Specific Changes Implemented
Flow of Process (Prior and Post)
Pie Chart will compare how effective they are Flow Chart, this will help to show where improvements can be made and where they have been successful Bar Chart, we can note the frequency and with a Pie Chart we can assess the types
All errors should be fully documented and be reviewed quickly with staff

Types of Errors, Near Misses and Their Frequency

All data will be periodically reviewed to assess for errors and possibility of improvement. When goals are met based on implementations, then the process may be presented to the rest of the facility, in order to restructure their processes accordingly and improve our quality outcomes. ***The PDCA process should continue until goals are surpassed for each clinical area.

RESOURCES
American Diabetes Association. (n.d.). Retrieved from http://www.diabetes.org/in-my-community/local-offices/honolulu-hawaii/ Centers for Disease Control and Prevention. (2009). National health interview survey. Retrieved from http://www.cdc.gov/diabetes/pubs/pdf/factsheet11_figures.pdf Cobaugh, D. J., Maynard, G., Cooper, L., Kienle, P.C., Vigersky, R., Childers, D., & Cohen, M. (2013). Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel. American Journal of HealthSystem Pharmacy, 70(16), 1404-1413. doi: 10.2146/ajhp130169 Mattox, E. (2012). Strategies for improving patient safety: Linking task type to error type. American Association of Critical Care Nurses, 32(1), 52-60, 78. doi: 10.4037/ccn2012303 Rubin, J. D., Russell, L. A., & Cohn, B. (2013). Transcription error results in medication dose that is fatal and $140 million verdict. Healthcare Risk Management, 1-3. Santell, J., Hicks, R., & Protzel, M. (2003). RN news watch: drug update. Error watch: is your patient a diabetic? Watch that insulin dose!. Rn, 66(10), 92. The Joint Commission. (1999, November 19). High alert medications and patient safety (11). Retrieved from http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_11.htm?print=yes U.S. Department of Health and Human Services. (2013, September 8). Diabetes national data. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/nationaldata.aspx?topicId=8

Ward, L. G., & Aton, S. S. (2011). Impact of an interchange program to support use of insulin pens. American Journal Of HealthSystem Pharmacy, 68(14), 1349-1352. doi:10.2146/ajhp100535