Running head: MEDICATION ERRORS INVOLVING INSULIN

Medication Errors involving Insulin:

Prevalence, Hazards and Techniques for Error Reduction
Michael A. Cook
University of South Florida

MEDICATION ERRORS INVOLVING INSULIN

Medication Errors involving Insulin: Prevalence, Hazards and Techniques for Error Reduction
One of the fundamental responsibilities of the nursing staff in a health care facility is to
safely administer the medications that are prescribed for a patient. These medications are
prescribed by a physician after gathering assessment data and determining potential interventions
and prospective outcomes. Although these medications are provided with the intention of
improving patient symptoms, illnesses or outcomes, there is an inherent risk involved in the
process of administration. Errors by hospital staff members involving medication administration
have been estimated to be over 200,000 annually (James, 2013). The most common medication
affiliated with these errors is insulin. Although insulin administration errors are common and the
consequences can be significant, primarily consisting of hypoglycemic events and reductions in
glycemic control, there are techniques employable that can help reduce the prevalence of such
errors.
Risks Leading to Insulin Administration Errors
One factor that contributes to the abundance of medication errors involving insulin is its
commonality. According to the National Hospital Discharge Survey compiled by the Center for
Disease Control and Prevention, approximately 20% of the thirty-five million hospitalized
patients documented had diabetes mellitus as a diagnosis (CDC, 2010). Patients with type 1
diabetes mellitus require exogenous injections of insulin to prevent hyperglycemia, and patients
with severe type 2 diabetes mellitus may also require exogenous insulin injections if their
physiological insulin production levels are markedly decreased (Osborn, Wraa, Watson, &
Holleran, 2014). Because these injections are most commonly given several times per day, this
leaves copious opportunities to administer exogenous insulin injections erroneously.

MEDICATION ERRORS INVOLVING INSULIN

Given insulins ability to reduce circulating blood sugar concentrations, a prominent risk
during administration is hypoglycemia as a consequence of poorly timed injections or excessive
quantities of drug volume. A study involving the analysis of over 1.6 million capillary blood
glucose readings in eights hospitals revealed an occurrence of hypoglycemia in approximately
26% of patients (Jones, Kasey, Perry, Kennon, & Sainsbury, 2014). A common insulin
administration regimen in the hospital is the injection of rapid-acting insulin before meals.
Rapid-acting insulin frequently has an onset of action less than fifteen minutes after
administration, therefore food needs to be consumed within a short period of time or else the risk
of hypoglycemia increases (Osborn, Wraa, Watson, & Holleran, 2014).
Insulin injections frequently involve the administration of very small volumes of fluid
due to the potency of the medication and its mechanism of action. Consequently, the withdrawal
and injection of insulin requires precise observation by nursing staff and careful adherence to
safety procedures. The sensitive nature of administration of medications with small, highlyspecific volumes inherently provides circumstances where risks are prominent and need to be
carefully monitored so as to avoid administration errors.
Clinical Consequences of Insulin Administration Errors
Many of the clinical consequences related to insulin administration errors are due to
hypoglycemic events. In fact, a review of over 800 patients receiving insulin injections at the
Rush Universe Medical Center in Chicago, Illinois, concluded that adverse outcomes, such as
ICU transfers and nosocomial infections, are more closely associated with events of
hypoglycemia than overall glycemic variability during a hospital stay (Kim, Rajan, Sims,
Wroblewski, & Reutrakul, 2013). Although an increase in glycemic variability may potentiate
risks of certain complications, hypoglycemic events themselves can also increase the risks of

MEDICATION ERRORS INVOLVING INSULIN

these adverse outcomes. Because hypoglycemia can readily be caused as a consequence of a

solitary error in insulin administration, safety and adequate precision are notably important in
every single injection.
Although patients with diabetes who are in need of regular insulin injections may only
reside in an acute care facility for a short period of time, clinicians are responsible for ensuring
that the patients glycemic levels are under control and remain within physiologically acceptable
bounds. This is especially important because high levels of glycemic variability have been found
to be correlated with an increased risk of both microvascular and macrovascular complications
over time (Kwok & Loke, 2015).
Techniques for the Reduction of Insulin Administration Errors
One of the simplest techniques employable to reduce insulin medication errors is simply
the act of rechecking the medication orders upon withdrawal from the Pyxis, entering the
patients room, and prior to administration. These consecutive checks will help to ensure that the
six rights of medication administration are evaluated and that the proper type of insulin and
proper quantity or administered at the right time to the correct patient.
One of the prominent consequences of improper insulin administration is the presentation
of hypoglycemia in an affected patient. This outcome can be reduced by ensuring that meals are
available for patients, and ensuring that the proper volume of insulin is withdrawn into the
syringe prior to administration. The former action can be enacted by ensuring that insulin
injections are given at the designated times, often scheduled before typical meal times in the
hospital, and by confirming with the patient that they have ordered a meal if such a meal is not
present with them at time of administration. A further step may be to recheck the patient record
so as to ensure that no dietary orders or restrictions have been modified on the patient.

MEDICATION ERRORS INVOLVING INSULIN

The latter technique of proper insulin withdrawal is also an important process in reducing
insulin-induced hypoglycemia and hyperglycemia because its helps to reduce the probability that
the patient is receiving a dose of insulin that is excessive or inadequate, respectively. Before
leaving the medication room with insulin, the volume of insulin withdrawn should be inspected
with the syringe vertical and with the clinicians eyes at the level of internal plunger.
Furthermore, because insulin requires specialized syringes it is important to double-check that
the proper syringe is being employed as the dosing of insulin is translated in terms of units as
opposed to milliliters.
Conclusion
Insulin is the most common medication error presented in hospital settings and it often
leads to bouts of hypoglycemia as well as compromised glycemic variability. Although the
frequency of such occurrences is high, there are employable techniques that are designed to
reduce the prevalence of these errors and consequently improve patient outcomes. It is important
for clinicians charged with the responsibility of administering insulin to triple-check medication
orders, ensure proper volume withdrawal, maintain the six rights of medication administration,
and ensure adequate nutrition is available for patients who are to receive exogenous insulin
injections.

MEDICATION ERRORS INVOLVING INSULIN

References
Center for Disease Control and Prevention. (2010). National Hospital Discharge Survey
[Data file]. Retrieved from
http://www.cdc.gov/nchs/data/nhds/10detaileddiagnosesprocedures/2010det10_number
alldiagnoses.pdf
James,J.(2013).ANew,EvidencebasedEstimateofPatientHarmsAssociatedwithHospital
Care.JournalOfPatientSafety,9(3),122128.
Jones, G., Casey, H., Perry, C., Kennon, B., & Sainsbury, C. (2014). Trends in recorded capillary
blood glucose and hypoglycaemia in hospitalised patients with diabetes. Diabetes
Research And Clinical Practice, 10479-83. doi:10.1016/j.diabres.2014.01.021
Kim, Y., Rajan, K. B., Sims, S. A., Wroblewski, K. E., & Reutrakul, S. (2014). Impact of
glycemic variability and hypoglycemia on adverse hospital outcomes in non-critically
ill patients. Diabetes Research And Clinical Practice, 103437-443.
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Kwok, C.S. , & Loke. Y. (2015). Long-term Glycemic Variability and Risk of Adverse
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Osborn, K.S., Wraa, C.E., Watson, A.B., & Holleran, R. (2014). Medical surgical nursing:
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