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Preventing Insulin Errors: Risk Reduction Strategies

From our partners at the Institute for Safe Medication Practices (ISMP): Organizations should strive to identify system-based causes of errors with the use of both insulin vials and insulin pen devices and implement effective types of error reduction strategies. Error reduction strategies such as constraints and standardization, which are more powerful because they focus on systems, will be more effective than education alone, which relies on individual performance and will likely be ineffective when used alone.

Constraints

Organizations should use strategies that lessen the chance of harm with the use of insulin. For example, an organization could attempt to reduce or limit the variety of insulin products on its formulary.27 In addition, organizations could remove patient-specific insulin vials, including U-500 insulin, from patient care areas upon patient discharge….

Standardization

Many strategies that could prevent harm with the use of insulin could be addressed by simplifying and standardizing the many processes surrounding its use. They include the following:

  • Standardize and simplify orders for insulin. 28
    • Develop standardized protocols and a standard format for prescribing insulin, preferably using preprinted order forms or electronic order sets that list specific products, ingredients, and component ratios.29
    • Include generic names for insulin products on protocols, computer screens, MARs, and labels, when possible, to reduce confusion between brand names.29
    • Establish a standardized algorithm within the organization for the dosing of insulin when providing coverage with meals.
    • Avoid the use of abbreviations or other shortcuts when communicating orders for insulin. Use the complete word “units” when expressing doses and concentrations of insulin.28 Do not use the abbreviation “U.” In addition, do not use “SSRI” as an abbreviation for sliding-scale regular insulin, because it has been misinterpreted as selective serotonin-reuptake inhibitor.29
    • Use a single, standard concentration for adult IV insulin infusions. If a nonstandard insulin concentration is needed, list the concentration and the patient’s dose in units and volume.29
    • Establish a plan for treating hypoglycemia for each patient. Track all episodes of hypoglycemia in the hospital.30
  • Safely store and dispense insulin.28
    • Do not keep insulin vials on top of medication carts or counters or under pharmacy compounding hoods, as insulin could be confused with heparin, which also is measured in units. Put all insulin back in the appropriate storage area immediately after use.28
    • Separate insulin products from one another in refrigerators (i.e., avoid storing multiple types of insulin together in a single bin). Consider using visual clues, such as affixing a photo to the bin of the vial that should be stored there, to help ensure that the correct vial is returned to the correct bin.
Differentiate

Employ strategies to distinguish or make insulin products different in appearance, such as the following:

  • Have pharmacy prepare and dispense prefilled syringes for once daily doses of long-acting insulin (e.g., insulin glargine).28
  • Emphasize the word “mixture” or “mix,” along with the name of the insulin product mixtures, for drug selection screens.29
  • Use tall man lettering in order-entry screens, medication administration records (MAR) and pharmacy labeling (e.g. NovoLOG, NovoLIN, HumaLOG, HumaLIN).
  • Apply bold labels on atypical insulin concentrations.27
Redundancies

For example, require an independent double check of all doses before dispensing and administering IV insulin. Build the double check into daily work processes so it can be accomplished without disruption.28

Education and Information

Education and information strategies include the following:

  • Provide staff with ongoing education about insulin products and methods of delivery.28
  • Prepare a chart that lists all insulin products used in your facility. Include generic and brand names; concentration; onset, peak, and duration of action; acceptable routes of administration; time of administration in relationship to meals; appropriate drug delivery devices; and special precautions (e.g., measuring the proper dose, mixing instructions, more frequent patient glucose monitoring). Pictures of the boxes in which insulin is packaged also would be helpful. Post the charts in areas where insulin is prescribed, dispensed, and administered.28
  • Check MARs and pharmacy labels to identify truncated information about insulin products and take steps to clarify important drug information as needed.23 Work with vendors to modify the appearance of MAR/eMAR and pharmacy labeling entries so that the wording is congruent with how medications will be administered (e.g., 10 units) rather than how they are supplied (e.g., 100 units/mL).28
Monitoring of Adverse Events

Historically, measurement efforts have focused on practitioner reporting of medication errors, which, at best, uncovers just a fraction of the errors, most of them harmless.32 Consider measures other than practitioner reporting of medication errors to evaluate your organization’s safe use of insulin, including the following examples:

  • Assess core processes associated with insulin use by using process measures.
  • Obtain outcome measures by evaluating patient records using a list of triggers is the most effective means of collecting data on adverse drug events.

(Click here to view or download a sample tool that can be used to identify and monitor actual or potential problems with the use of insulin.)

U-500 Insulin Strategies

Strategies unique to the use of U-500 insulin include the following:

  • Ensure consistent use of a tuberculin syringe with U-500 insulin, with total doses expressed in terms of both units and volume (e.g., 200 units [0.4 mL]).33
  • Establish a practice to have pharmacy draw up and dispense the ordered dose of U-500 insulin with a second individual (e.g., nurse, technician) performing an independent check of the vial, syringe, and contents.25
Bedside Blood Glucose Monitoring

Organizations must determine the safest way to receive, document, communicate, and verify glucose meter readings. Sample strategies include the following:

  • Nurses need to know patient’s blood glucose level before administering insulin. A flow sheet for recording each dose of medication and corresponding lab values allows nurses to review previously administered doses and track the patient’s overall response to therapy.34
  • Require nursing assistants to write the patient’s blood sugar on the MAR so the nurse can give the correct amount of insulin.23
  • Discourage verbal communication of blood glucose results.
Courtesy of ISMP.org
Notes
  1. National Diabetes Information Clearinghouse. National Diabetes Statistics, 2007. Prevalence of Diagnosed and Undiagnosed Diabetes in the United States, All Ages, 2007 [online]. 2008 Jun [cite 2009 Aug 27]. Available from Internet: http://diabetes.niddk.nih.gov/DM/PUBS/statistics/#allages.
  2. National Diabetes Information Clearninghouse. National Diabetes Statistics, 2007. Treating Diabetes [online]. 2008 Jun [cited 2009 Aug 27]. Available from Internet: http://diabetes.niddk.nih.gov/DM/PUBS/statistics/#treating.
  3. Institute for Healthcare Improvement. Implement Effective Glucose Control [online]. [cited 2009 Oct 29]. Available from Internet: http://www.ihi.org/IHI/Topics/CriticalCare/
    IntensiveCare/Changes/ImplementEffectiveGlucoseControl.htm
    .
  4. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001 Nov 8;345(19):1359-67.
  5. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009 Mar 26;360(13):1283-97.
  6. Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA 2008 Aug 27;300(8):933-44.
  7. Cohen MR, Proulx SM, Crawford SY. Survey of hospital systems and common serious medication errors. J Healthc Risk Manag 1998 Winter;18(1):16-27.
  8. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). NCC MERP index for categorizing medication errors [online]. 2001. [cited 2009 Aug 27]. Available from Internet:
    http://www.nccmerp.org/pdf/indexColor2001-06-12.pdf.
  9. U.S. Pharmacopiea. MEDMARX data report. Technical appendix 12: products most frequently involved in harmful medication errors (Categories E-I), CY 2006 [online]. 2008 [cited 2010 Feb 4]. Available from Internet: http://www.usp.org/pdf/EN/medmarx/2008MEDMARXReport.pdf.
  10. Focus on high-alert medications. PA PSRS Patient Saf Advis [online] 2004 Sep [cited 2009 Nov 11]. Available from Internet: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2004/Sep1(3)/Documents/06.pdf.
  11. Institute for Safe Medication Practices. Proliferation of insulin combination products increases opportunity for errors. ISMP Med Saf Alert 2002 Nov 27;7(24):2.
  12. Institute for Safe Medication Practices. Complexity of insulin therapy has risen sharply in the past decade—part I. ISMP Med Saf Alert 2002 April 17;7(8):1.
  13. Institute for Safe Medication Practices. Safety Brief. ISMP Med Saf Alert 2000 May 3;5(9):1.
  14. Institute for Safe Medication Practices. Getting the right insulin is becoming a real crapshoot. ISMP Med Saf Alert 2004 Jul 15;9(14):2.
  15. Complexity of insulin therapy. PA PSRS Patient Saf Advis [online] 2005 Jun [cited 2009 Nov 11]. Available from Internet: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2005/jun2(2)/Documents/30.pdf.
  16. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004 Feb;27(2):553-91.
  17. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group.
    N Engl J Med 1993 Sep;329(14):977–86.
  18. Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med 1997 Mar 10;157(5):545-52.
  19. Gearhart JG, Duncan JL 3rd, Replogle WH, et al. Efficacy of sliding-scale insulin therapy: a comparison with prospective regimens. Fam Pract Res J 1994 Dec;14(4):313-22.
  20. Baldwin D, Villanueva G, McNutt R, et al. Eliminating inpatient sliding-scale insulin: a reeducation project with medical house staff. Diabetes Care 2005 May;28(5):1008-11.
  21. Magee MF, Clement S. Subcutaneous insulin therapy in the hospital setting: issues, concerns, and implementation. Endocr Pract 2004 Mar-Apr;10 Suppl 2:81-8.
  22. Cohen MR. Medication Error Reports. Hosp Pharm 1975 Mar;10(3):120.
  23. Institute for Safe Medication Practices. Don’t try to “sweet talk” me! ISMP Med Saf Alert 2003 Nov 27; 8(24):1.
  24. Institute for Safe Medication Practices. Safety brief: insulin concentrate U-500. ISMP Med Saf Alert 2007 Jul 26;12(15):1.
  25. Institute for Safe Medication Practices. Insulin syringe is not meant for U-500 insulin. ISMP Med Saf Alert 2001 Oct 17;6(21):2.
  26. Institute for Safe Medication Practices. Safety brief. ISMP Med Saf Alert 2001 Mar 21;6(6):2.
  27. Cohen MR, Di Domizio G, Lee RE. The role of drug names in medication errors. In: Cohen MR. Medication errors, 2nd ed. Washington (DC): American Pharmaceutical Association; 2007.
  28. Institute for Safe Medication Practices. Complexity of insulin therapy has risen sharply in the past decade—part II. ISMP Med Saf Alert 2002 May 1;7(9):1-2.
  29. Cohen MR, Smetzer JL, Tuohy MR, et al. High alert medications: safeguarding against errors. In: Cohen MR. Medication errors, 2nd ed. Washington (DC): American Pharmaceutical Association; 2007.
  30. American Diabetes Association. Standards of medical care in diabetes—2009. Diabetes Care 2009 Jan; 32 Suppl 1:S13-61.
  31. Institute for Safe Medication Practices. Restricted character space and truncated drug listings are a set-up for medication errors. ISMP Med Saf Alert 2008 Jun 5;13(11):3.
  32. Institute for Safe Medication Practices. Measuring up to medication safety. ISMP Med Saf Alert 2005 Mar 10; 10(5):1.
  33. Institute for Safe Medication Practices. Extra caution needed with U-500 insulin. ISMP Med Saf Alert 1997 Jan 29;2(2):2.
  34. Smetzer JL, Cohen MR. Preventing drug administration errors. In: Cohen MR. Medication errors, 2nd ed. Washington (DC): American Pharmaceutical Association; 2007.
Self-Assessment Questions

The following questions about this article may be useful for internal education and assessment. You may use the following examples or come up with your own.

  1. What is the most common type of reported medication error associated with the use of insulin?
    1. Wrong drug
    2. Wrong dose/overdosage
    3. Dose omission
    4. Extra dose
    5. Wrong dose/underdosage
  2. Breakdowns or errors that lead to reported wrong-dose medication errors associated with insulin include all of the following EXCEPT:
    1. Use of insulin coverage orders
    2. Ambiguous orders written by prescribers
    3. Inaccuracies when obtaining and/or using a patient’s blood glucose value
    4. Errors when transcribing and entering orders into a computer system
    5. Use of a standardized protocol or order form to order insulin
  3. Which of the following statements about the reported wrong-drugs errors associated with insulin products is INACCURATE?
    1. A majority of the submitted wrong-drug reports did not list a specific insulin product or listed names of products that do not exist.
    2. Wrong-drug insulin errors included breakdowns that occurred when retrieving the medication from stock or an automated dispensing cabinet.
    3. Most of the submitted reports that occurred during the prescribing phase involved the clarification of nonspecific orders (i.e., a specific insulin product was not indicated).
    4. The most common type of wrong-drug errors involving insulin occurred when insulin vials were mislabeled in the pharmacy.
    5. Most of the wrong-drug errors involving infusion bags containing insulin reached the patient.
  4. All of the following strategies can be used to prevent errors with the use of insulin EXCEPT:
    1. Limiting the variety of insulin products on an organization’s formulary
    2. Establishing a standardized algorithm for dosing insulin when providing coverage with meals
    3. Using multiple, patient-specific concentrations for adult IV insulin infusions
    4. Having pharmacy prepare and dispense prefilled syringes for once-daily doses of long-acting insulin
    5. Requiring an independent double check of all doses of insulin before dispensing and administering IV insulin infusions
  5. Which of the following statements about concentration and U-500 insulin is INACCURATE?
    1. The use of U-500 insulin has been increasing due to factors including an escalating obesity epidemic, increasing insulin resistance, growing use of insulin pumps, and rising usage of high doses for tight glucose control.
    2. Prescribe U-500 insulin in units based on a U-100 syringe.
    3. There are no insulin syringes designed to measure doses of U-500 insulin.
    4. Use tuberculin syringes when administering U-500 insulin, with total doses expressed in terms of both units and volume (e.g., 150 units [0.3 mL]).
    5. Establish a practice to have pharmacy draw up and dispense ordered doses of U-500 insulin.
  6. A physician wrote an order for a patient to “decrease Lantus insulin to 8 u qd,” but the order was transcribed as 80 units. The medication was administered as transcribed, and the patient’s blood sugars were documented as 40 mg/dl.Predict which of the following strategies would NOT help prevent this event from reoccurring.
    1. Develop a standard format for prescribing insulin, preferably using preprinted order forms or electronic order sets that list specific products, ingredients, and component ratios.
    2. Avoid the use of abbreviations or other shortcuts when communicating orders for insulin.
    3. Use tall man lettering in order-entry screens, medication administration records, and pharmacy labeling.
    4. Require an independent double check of all doses before dispensing and administering IV insulin.
    5. None of the above
Courtesy of ISMP.org

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Diabetes in Control would like to acknowledge the Institute for Safe Medication Practices’ outstanding work in medication safety, including the above excerpt.

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Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.

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