A multi-system approach to reducing insulin errors

Abstract

Background

Insulin prescribing and administration errors are consistently high with respect to hospital in-patients. There is no straightforward solution to the problem as there are multiple causative factors and system failures. We describe the implementation of a multi-system approach which looks at changes across the board to avoid the risk of serious harm in a teaching hospital setting.

Methods

Organizational level changes included addressing the development of a culture of safety and promoting management buy in. Clinical level changes relate to the labelling and storage of insulin and the provision of accessible information for clinical staff in several different formats. Patient level changes were directed at improving the prescription charts with their own specific insulin section as well as empowering patients to retain the control of their own insulin administration.

Results

Following the initial phase of the project the number of clinical incidents relating to insulin administration and prescribing increased by 18%.

Discussion

The surprising initial outcome was felt to reflect an increased awareness of the issues surrounding insulin problems and the fact that they were previously under-reported. The project has had strong support and good feedback from a wide array of healthcare professionals within the hospital trust. The national diabetes in-patient audit will allow an opportunity for further analysis and a longer time frame for the multi-system changes to bed in.

Introduction

Insulin prescriptions constitute a high number of medication errors within hospitals nationally and have the potential to cause significant adverse effects (according to clinical incident/DATIX data and Diabetes team spot audits).

Research on the safe use of insulin in hospitals has mainly focused on changing protocols and guidelines, but it is important to recognize that a multi-system approach is preferable in line with the NPSA's latest guidance on reducing harm from high risk medications.^1–3

This involves:

- Organizational level changes

- Clinical area changes

- Patient level changes

At the most basic level of prescribing and administration, the commonest causes of insulin drug errors are caused by:⁴

dosage errors,

illegibility,

incomplete prescriptions,

errors in dosing interval,

incorrect insulin formulations,

misunderstandings of the mealtime – insulin administration relationship,

failure to change insulin prescriptions in the face of severe dietary restrictions eg. NBM, parenteral feeding

drug interactions,

transcriptions errors.

As well as the common mistake of ‘U’ being written for units and being mistaken for an extra 0, (12U read as 120) leading to ten times drug errors.

It is therefore sensible to acknowledge that ‘trying harder’, more training, or new protocols alone will not overcome these systems errors. We should recognize that human errors will occur and design around this fact.

Below is a summary of recommendations for changes to clinical and organizational practice which are designed to overcome the perceived, relatively ‘simple’ problem of insulin prescribing and administration errors. They are based on best practice guidelines and the latest literature and have been adapted for in-patient hospital wide use.^5–8

This project was designed to utilize minimal resources and is specifically intended to avoid major changes in practice and the need for extra training of junior doctors, nurses and pharmacists. This also differs from the NHS Institute for Innovation's ‘THINK GLUCOSE’ programme, although we have adopted some of their better ideas.

Evaluation is built in, although it may be difficult to tease apart which of the raft of measures has the most impact. The point ultimately being that we need to do everything we can across the board to increase safety and reduce the high rate of errors associated with this common drug.

Methods

Organizational level changes

Categories	Potential changes/action	Goal
Policies and guidance	– Insulin management protocol – review and update	Prevention
Monitoring and controlling usage	– Make insulin a ‘high alert’ medication which requires double checking prior to administration (high alert meds = drugs that bear a heightened risk of causing significant patient harm when they are used in error)	Prevention
Culture	– Promoting a culture of safety – highlight to hospital staff the significance of insulin errors poster & email & intranet approach, including information sheets in drug cupboard areas	Prevention
Management	– The clinical director with responsibility for CQUIN (commissioning for quality and innovation = healthcare policy incentive scheme) needs to be involved. A percentage of the hospital budget is withheld by the SHA unless certain clinical safety and quality issues are addressed.	Financial and management buy in
Accessible information	– Diabetes / Insulin intranet site – see below	Prevent and inform

Diabetes/Insulin Intranet site – easily accessible from intranet front page, to include information and pictures about types of insulin, administration, harm avoidance and management of hypo and hyperglycaemia. Along with contact numbers for the inpatient diabetes team.

Communications/Project Awareness – part of creating a culture of safety is to generate an understanding and engagement with the health care professionals involved in the prescribing and administration of high risk medications such as insulin. This needs to take place at both an individual and organizational level. Both poster campaigns and regular e-mail updates/newsletters are a first step in communicating the aims of a patient safety project.

Clinical Area level changes

Categories	Potential changes/action	Goal
Labelling and storage	– Label all insulin vials and devices with the patients name and details (not currently standard practice, especially in acute areas)	Prevent
Compliance	– Review processes for patients managing their own insulin (patients with diabetes have long experience in insulin dose adjustment and self administration).	Prevent
	– Ensure that each ward has a nominated Diabetes link nurse	Inform
Education and training	– Education of health professionals in the identification of both over dosage and under dosage.	Identify
	– Ensure staff training reflects increasing complexity of insulin types, device and prescribing.	Prevent
	– Develop regular bulletins describing updates and changes to types of insulin and devices.	Inform
Accessible information	– Utilising small, pocket sized, laminated cards to give an outline of local hospital management protocols. This is useful for juniors as it covers both insulin prescribing and the most important aspects of diabetes in-patient management eg. dose adjustment, steroids, NBM in diabetic patients.
	– Both the cardiology and microbiology departments have already successfully used similar methods

E.g. Treatment of Hypoglycaemia (this can be modified to fulfill local guidance)

Patient level changes

Categories	Potential changes/action	Goal
Prescribing	– When prescribing, specify the exact brand name and if possible specify whether a vial, cartridge or pen is required.	Prevent
	– Spell out the word ‘units’ instead of ‘u’ or ‘iu’
	– Consider the use of preprinted insulin orders, with the word UNITS already included
	– A designated area on the drug chart either for insulin alone (such as the current Warfarin section) or to include an area for complex and variable prescriptions – this would then provide an opportunity for clearer prescribing of several drug types whose dose changes e.g. Gentamicin, Methotrexate, insulin and consequently have the potential to reduce the risks of errors for several other medications as well	Prevent
Administration	– Implement a double check system before administration of insulin to the patient
	– Coordinate meal and insulin times
Monitoring effects	– Ensure appropriate monitoring through more rapid/regular testing of blood sugars.	Prevent and identify
	– Consider updating / modernising capillary blood glucose charts
	– Ensure that appropriate insulin, glucagon and glucose are readily available	Mitigate
Upskilling of Pharmacists	– Induction and training programmes for pharmacists should assess or include training on how to complete a clinical check of prescriptions. A competency-based programme should be introduced to ensure staff can accurately clinically check discharge prescriptions. There should be regular revalidation of staff who carry out this process to maintain high standards.	Prevent and MitigateTo liaise with pharmacy
Patient empowerment	– Enable patients who are able to monitor and adjust their own insulin treatment to continue doing so (this requires judgement and is line with the self management of diabetes in hospital guidance)	Prevent

E.g. New drug chart with specific Insulin section

E.g. Simplified capillary blood glucose monitoring chart.

How to manage high blood glucose (hyperglycaemia) in unstable patients

Capillary blood glucose (CBG) should be monitored pre-meals and 2 hours post meals, at bedtime and 3am

If blood glucose > 10mmol/l give 5% of the total insulin dose prescribed from the previous 24 hours, as fast acting insulin

If blood glucose >15 mmol/l give 10% of the total insulin dose prescribed from the previous 24 hours, as fast acting insulin

TOTAL INSULIN DOSE = number of units of insulin (fast or long acting) that have been administered during the previous 24 hours assuming that the previous 24 hours have controlled blood glucose.

If the patient needs repeated doses of supplemental insulin >48 hours, please contact the in-patient Diabetes specialist nurse for further advice.

DO NOT JUST REPEAT SUPPLEMENTAL DOSE PRESCRIPTIONS. Incorporate supplemental doses into regimen to ensure optimal glucose control and targets are achieved.

How to be a safer Insulin prescriber:

Right Insulin – check the name and type of Insulin. Write it up clearly in CAPITAL letters

Right Dose – make sure UNITS isn't confused for an extra ZERO (U)

Right Time – With food? (Reduce the Food- Insulin gap). At bedtime?

Right Way – sub-cut or IV?

Right Patient – show them the insulin and say what you are about to do

Safe discharge;

If new to sub-cut insulin therapy, ensure that patients are seen by the DSN prior to discharge.

All patients with diabetic ketoacidosis (DKA)/hyperosmolar non-ketotic state (HONK) should be seen by the Diabetes team prior to discharge to evaluate the precipitating cause of their admission.

Project Evaluation

The ultimate aims of this project are to highlight the issues around insulin prescribing and improve:

Overall quality of care

Patient safety

Diabetes team utilization

Knowledge and awareness among hospital staff

Patient satisfaction

Staff satisfaction

We wish to reduce the following:

Insulin drug errors

Adverse incidents such hypo/hyperglycaemia, deranged glycaemic control

Cancelled operations/procedures

Complaints

Delays in discharge/overall LOS for diabetic patients

Inappropriate referrals to the specialist team.

The approach to evaluation will be through DATIX (clinical incident) data, further spot audits and the use of structured methods for evaluation.

Many of these recommendations could apply to other high risk medications, but insulin is a good one to tackle first because of the sheer number of the clinical incidents previously reported and the available evidence about making a difference. This project therefore represents a multi-systems approach to tackling the problem of insulin prescribing errors and is aligned with the trust goals of ‘best and safest care’.

Discussion/Analysis

Reducing harm from high risk medications in a hospital environment remains a ‘wicked’ problem. It is not one that can be solved by instructing people to ‘try harder’ or ‘be more careful’. It represents the opportunity to tackle unsafe systems and promote a culture of safety, whereby everything we do is aimed at limiting the risk of serious errors in a vulnerable patient group.

Take for example, the common practice of taking away control of an individual's insulin cartridges and pens when they are admitted to hospital and locking them away in a box next to a patient's bed. This may represent a form of psychological torture in which the patient is far more aware of their glycaemic needs than the busy or poorly trained nursing staff with sub-optimal understanding of the need for regular, timely insulin administration.

The aim of the above multi-system based interventions is to tackle every possible source of error along the line of admission through to prescription and administration. The initial outcome is somewhat surprising and perverse, in that the number of insulin prescribing and administration errors has actually significantly risen following the initiation of this project. Rather than reflecting that the situation has worsened, this suggests that previously the true extent of the problem was even greater than first thought. Healthcare professionals are now more aware of the problems relating to insulin and are therefore more likely to formally report them. We will have to wait until the annual diabetes multi-disciplinary team's hospital-wide in-patient audit, to have a fuller idea of the effect that these changes have made. But at least this will allow an opportunity for the interventions to bed in. A key ideal is to maintain the momentum and ensure that our approach to in-patient drug delivery, not just for insulin, is transformative and becomes a safe and effective system rather than the current unsatisfactory approach.

Footnotes

Acknowledgments

Many thanks to Dr. Nick Vaughan, Dr. Andy Smith, Kate Morel, Josie Wilson, Nikki Robinson, Mark Renshaw, Professor Aidan Halligan, Jatinder Harchowal, Emma Williams, Derek Lington, Dr. Rif Malik, Dr. Anna Crown and Dr. John Quin.

References

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. Safe Insulin Use in the Hospital setting. Hosp Pract 2009 Dec; 37(1): 51–59

Cohen

. Pharmacists Role in ensuring safe and effective hospital use of insulin. Am J Health Syst Pharm 2010 Aug; 67 (16 Suppl 8): S17–21

Patient Safety First campaign; http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/High-riskmedication/ and www.patientsafetyfirst.nhs.uk/content/medicationsafety/insulin/

Wesorick

, Effects of an educational programme and a standardized insulin order form on glycaemic outcomes in non-critically ill hospitalized patients. J Hosp Med 2010 Oct; 5(8): 438–45

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. Reducing insulin medication errors: evaluation of a quality improvement initiative. J Nurs Staff Dev 2003; 19: 92–98

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, Glycaemic Control in hospitalized patients: beyond sliding scale insulin. Am Fam Physician 2010 May 1: 81(9): 1130–5