Medication Safety:

Reducing Insulin Errors

University of South
Florida
College of Nursing
 Quality Improvement: Why Insulin?

➔ Define the problem:

◆ Institute of Medicine’s, To Err is Human, reported as many as 7,000 Americans die
from medication errors each year¹
◆ About $16.4 billion is spent every year on inpatient preventable medication errors2
◆ 8% of all medication errors leading to an emergency department visit included
insulin³
◆ Of all medication errors in 2005 made by healthcare professionals, 4% included
insulin4
◆ A study by the Institute for Safe Medication Practices (ISMP) reported 11% of all
serious medication errors involve insulin in 19984
◆ ISMP also says these insulin errors have been occurring for more than 30 years4
Measure: Current Practices & How They Go
Wrong
● Hospitals use insulin to treat hyperglycemia
● Most errors result in hypoglycemia
● All patients with diabetes should have their A1C measured in the hospital if it hasn’t been done in the
past 3 months
● Bedside glucose monitoring is implemented in all patients diagnosed with diabetes⁵ (American
Association of Clinical Endocrinologists).
● Sliding scale is also still widely implemented even though it’s not recommended⁶ (Management of
Diabetes Mellitus in Hospitalized Patients).
● Prescribing errors are the leading cause of insulin related errors
● According to the ISMP there has been numerous cases where U-500 insulin has been accidentally used
instead of U-100 resulting in 5 times the prescribed dose
● Insulin has been confused with other medications such as heparin⁷ (Enhancing Insulin-Use Safety in
Hospitals: Practical Recommendations from a)
Analyze: Factors Involved in Errors
● Prescribing:
○ Incorrect dosing
○ Irrational insulin orders
○ Nomenclature-related errors⁷
● Transcribing:
○ Transcribing telephone or verbal orders incorrectly
○ Incorrectly transcribing the dose⁷
● Dispensing & Storage:
○ Look-alike containers
○ Not double-checking insulin products before administration
○ Non-segregated/non-secure storage of insulin in patient care areas as well as pharmacy areas⁷
● Administration:
○ Administering the wrong dose
○ Improper use of insulin pens
○ Name confusion
○ The relationship between insulin administration to nutrition⁷
○ Especially mistaking the abbreviation "u" for units with the number 0.4
● Monitoring:
○ Failure to monitor the effects of insulin and adjusting the dose accordingly⁷
Plan: So Now What?
● IMPROVE
● Objective: To reduce insulin related medication errors
● Prediction: to reduce insulin medication errors by 30% within six months
● Plan to carry out the cycle:
○ Store U-100 insulin away from all other medications7
■ Commonly confused with U-500 insulin and heparin
■ U-500 insulin should be secured in the pharmacy department
○ Initiate/maintain nurse double check7
○ Insulin pen education - cost effectiveness!8
○ Surveillance of patients receiving insulin7
○ Standardized education/competency to health professionals7
○ Develop evidence-based protocols/order sets7
Do!
● Carry out the plan:

○ Nurses, patient-care technicians, physicians

● Implement & maintain hospital protocols/order sets

● Collection of abnormal data, blood glucose surveillance

○ Track all hypoglycemic and hyperglycemic events for patients receiving

insulin!8

● Interpret data - what does it say?

● Results in comparison with prediction

Study
● Evaluation of interventions:
○ Can nurses correctly demonstrate the administration of insulin?
■ Congruent with hospital policies
○ Do patient care technicians perform blood glucose monitoring correctly and in a timely
manner?
■ Adjustment of insulin dose if needed
○ Are new diabetic patients provided with thorough teaching regarding insulin administration?
■ Administration sites, use of insulin pen, signs of hypoglycemia, sick days
○ Does computerized charting reduce transcription errors?
■ Name confusion - tall man lettering
■ Incorrect dose
○ Are nurses performing insulin administration post-assessments at the correct time?

Ultimately… are less medication errors involving insulin administration being made?
Act
● Various methods of new diabetic patient teaching
○ Flyers, videos, classes, support groups
○ Patient satisfaction surveys
● Communication with pharmacy department
○ Insulin storage, security, timing
● Insulin administration post-assessment time frame
○ Depends on type of insulin administered
○ Did the amount/type of insulin given successfully stabilize patient’s blood
glucose?
● Correct implementation of nurse double-check
○ Computerized prompting
Control: Ensure New Practices Persist
● Track performance monthly9
○ Moving toward goal, or backtracking?
○ Process will fail if it does not improve frustration and work10
■ Success is dependent upon individuals wanting it to succeed
● Encourage feedback11
○ Vital for improving the new practice
■ Process can be improved, which encourages continuation of practice
● Celebrate successes9
○ Encourages individuals to be persistent
● Keep moving forward11
○ Quality improvement is a continuous process that never stops

“In everything you do, work to create processes that offer patients optimal care and service. At the same time,
work to decrease irritation, decrease work, and improve profits. No fancy gimmicks are necessary to gain
buy-in or maintain momentum if you can do these things. And no fancy gimmicks can save a new process if it
fails to pass this test.”9
References
1. Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: The National Academies Press.
doi: 10.17226/9728
2. Network for Excellence in Health Innovation. (2011). Preventing medication errors: A $21 billion opportunity. Retrieved from:
https://www.nehi.net/bendthecurve/sup/documents/Medication_Errors_%20Brief.pdf
3. Budnitz, D.S., Pollock, D.A., Weidenbach, K.N., Mendelsohn, A.B., Schroeder, T.J., & Annest, J.L. (2006). National
surveillance of emergency department visits for outpatient adverse drug events. JAMA, 296(15), 1858–1866. doi:
10.1001/jama.296.15.1858
4. Hahn, K. L. (2007). The "top 10" drug errors and how to prevent them. Medscape Pharmacists. Retrieved from:
https://www.medscape.org/viewarticle/556487
5. Handelsman, Y., Bloomgarden, Z. T., Grunberger, G., Umpierrez, G., Zimmerman, R. S., Bailey, T. S., Blonde, L. (2015).
American association of clinical endocrinologists and American college of endocrinology-clinical practice guidelines for
developing a diabetes mellitus comprehensive care plan. Endocrine Practice, 21(1). Retrieved from:
https://www.aace.com/files/dm-guidelines-ccp.pdf
6. McCulloch, D. K., Inzucchi, S. E. (2017). Management of diabetes mellitus in hospitalized patient. Retrieved from:
https://www.uptodate.com/contents/management-of-diabetes-mellitus-in-hospitalized-
patients?search=Management%20of%20diabetes%20mellitus%20in%20hospitalized%20patients&source=search_result&select
edTitle=1~150&usage_type=default&display_rank=1
References
7. Cobaugh, D. J., Maynard, G., Cooper, L., Kienle, P. C., Vigersky, R., Childers, D., Weber, R., (2013). Enhancing insulin-use
safety in hospitals: Practical recommendations from an ASHP foundation expert consensus panel. American Journal Health-
System Pharmacists 70. Retrieved from: http://eds.a.ebscohost.com.ezproxy.lib.usf.edu/ehost/pdfviewer/pdfviewer?
vid=5&sid=cb121595-a677-405e-802e-1e1093cbf6f8%40sessionmgr4008
8. Institute for Safe Medication Practices. (2017). ISMP guidelines for optimizing safe subcutaneous insulin use in adults. Retrieved
from https://www.ismp.org/sites/default/files/attachments/2017-11/ISMP138-Insulin%20Guideline-051517-2-WEB.pdf
9. U.S. Department of Health and Human Services. (2011). Quality improvement. Retrieved from: https://www.hrsa.gov/sites/defaul
t/files/quality/toolbox/508pdfs/qualityimprovement.pdf

10. Institute for Safe Medication Practices. (2014). High-alert medications in acute care settings. Retrieved from:
https://www.ismp.org/recommendations/high-alert-medications-acute-list

11. Giovino, J.M. (1999). Holding the gains in quality improvement. Family Practice Management, 6(5), 29-32. Retrieved from:
https://www.aafp.org/fpm/1999/0500/p29.html