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Best Ideas for Preventing Insulin Errors from the DIC Community

Nov 28, 2015

Best Ideas for Preventing Insulin Errors from the DIC Community

Diabetes In Control readers submitted their best advice on how to prevent insulin errors at home, at pharmacies, and in the hospital. We’re happy to present the winning entry, by Joyce Larson, as well as a selection of other excellent entries.

Winning Entry: Joyce Larson’s practical advice for managing insulin use

  • Set alarms on your phone to remind you when to take a shot.
  • Have a list of the insulin amounts near where you keep the insulin as a reminder.
  • Keep a chart of when you BS has gotten too high after eating a certain food so you remember not to eat that again or only eat it when you BS is a bit too low.

Diabetes educators and HCPs offered their tips for educating, advising, and observing patients to help prevent errors:

Return demonstration by patient — possibly more than once.  Add scenarios that allow the patient to change units on pen or syringe. Watch and assess. – Teresa Morris

Keep rapid-acting insulin on kitchen table or counter. Keep long-acting insulin on bedside table, never in the same place the rapid-acting insulin is stored. – Christine Kane

Take out the number of syringes you will need for the day. This eliminates forgetting to take it. It also lets you know that you already took it, if you forget. – Linda Donaldson

In our hospital the bedside nurses administer insulin via insulin pen. We have a label that is attached to all pens prior to delivery to the floor. It is placed over the seam of the pen so that it must be torn when the pen is first opened. This assures that the pen has not been used on anyone else. The label additionally has the words in bold red. SINGLE USE PATIENT ONLY. This has kept us adhering to the one patient one pen guidelines from the CDC and avoided any cross contamination. The pen is additionally scanned and 5 rights are followed as well as double checked by an RN. – Janet Howard-Ducsay RN CDE

Marking the pen to help prevent errors was popular advice:

To remember whether one has taken a pen-injected dose, write on the pen itself the date and meal when injected. – Reenie Marshall

1) Put masking tape on the insulin pen (not on the cap) to indicate if it’s a basal (” long acting”) or Bolus (” meal time”) in order to prevent errors in taking the wrong insulin. 2) To prevent patients who take small doses of insulin from using it beyond the expiration dates, write down the date when it needs to be discarded. For example, if they opened a new pen on the 2nd of March, they can write down 30th of March to indicate that it should not be used beyond that date. 3) Before traveling, make sure that not only are the insulin pens packed, but open them to see how much insulin is left in the pens, so that they are not going to run out of insulin. – Vasanthi Prabhaker

Finally, many readers offered “wish lists” for changes in products or industry that could also help prevent errors:

Considering that the NovoPen echo now has the ability to show last insulin dose and timing, I wonder if it would be possible to build in a small alarm. The biggest and most concerning mistake patients make is administering the dose of their long acting insulin via a short acting insulin pen.  This often results in a trip to the ER and serious concern for the patient being able to keep up with carb intake to offset the large dose of rapid acting insulin. Much like a pump has max basal and bolus amounts, it would be nice to see a pen with a memory that can provide a small audible tone when a dose that is above average is dialed. – Erin Kelly

Come up with insulin syringes with bigger markings so people can readily see the lines so accurate insulin doses can be drawn, which will prevent from either over dosing or under dosing. – Ok Chon Allison

Design a protocol or guidelines for prescribing insulin, dispensing insulin and giving insulins. Eliminate  abbreviations for all insulins. Eliminate sliding scales and hold insulins, eliminate telephone orders for insulin except in emergency in which a read-back is enforced. All written insulin orders should be accompanied by patient’s blood glucose level. – Regina Udoh