Insulin Error Reporting

Insulin Error Reporting

Literature Review

Insulin is widely considered to be one of the most important and beneficial drug discoveries of the 20th century. Its therapeutic benefits are undeniable when health care processes are designed withappropriate safeguards. However, preventable patient harm associated with errors involving insulin use continues to be a problem in many hospitals.

Despite the substantial attention to medication safety in general, and insulin safety specifically, evidence over the past 10 years suggests that patient injuries are still occurring. Insulin consistently appears as a top offender, leading to the most harmful and severe adverse events on the list of highalert drugs published by the United States Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP). The purpose of this report is to assist health care organizations and practitioners in improving the safety and effectiveness of insulin use in hospitalized patients (www.ashp.org). This report strives to provide a comprehensive set of recommendations and, therefore, incorporate and cite numerous and diverse resources.

The recommended safer insulin therapy practices guidelines are intended to meet and exceed current regulatory and accreditation (JCAHO) standards and recommendations of professional bodies [American Association of Clinical Endocrinologists (AACE), American Diabetes Association (ADA), American Society of Health-System Pharmacists (ASHP), ISMP, and USP] as well as to drive improvements in the standards of care.

The format of this report as a list of best practices characteristics was adapted from the ISMP, which has successfully assisted organizations in medication-safety assessments and guided improvements (patientsafetyauthority.org). Each of the recommendations includes its own set of references. The referenced resources should be used to provide additional information and specific details that will be necessary for effective implementation of safer insulin practices within health care organizations.

Twelve percent of patients discharged from hospitals carry the diagnosis of diabetes, and up to twenty-five percent of all hospitalized patients meet the criteria for the diagnosis of diabetes (Clements, ADA 2005a). Factors such as medications and stress cause many non-diabetic patients to develop hyperglycemia while hospitalized. Insulin is used in both of these populations to manage hyperglycemia. With such frequent use of insulin comes the risk of error and subsequent patient harm.

Types of insulin-use errors include:

Types of insulin-use errors include:

Administration of a wrong dose,

Administration to the wrong patient,

Use of the wrong insulin type,

Administration via the wrong route,

Wrong timing of doses,

Omission of doses,

Failure to properly adjust insulin therapy

Improper monitoring, timing, and assessment of blood glucose (BG) results. (www.ashp.org)

A 1998 Institute for Safe Medication Practices (ISMP) study found that 11% of serious medication errors involve insulin misadministration.1 With the rising prevalence of diabetes in recent years has come a corresponding increase in the use of insulin. Though it is often the most effective treatment for this chronic disease, data derived from scientific research and adverse event reporting systems such as PA-PSRS show that errors related to insulin are frequent and often cause significant patient harm. In fact, nearly 16% of all medication errors classified as Serious Events in PA-PSRS involved the use of insulin ...