Quality Standards for Diabetes Care Toolkit

Insulin safety and reducing errors

Waitemata DHB recognised a problem with insulin errors and developed processes involving hospital pharmacists to reduce errors. The model was presented at the NZSSD Annual Scientific Meeting in 2012 and is summarised on the HIIRC site as follows:

‘Unfamiliarity with new insulin preparations and ‘mixes’ among hospital staff, together with insulin timing errors, food delays and inaccurate drug history, have caused a number of insulin prescribing and administration errors in hospital wards. This clinical governance issue has prompted the diabetes team at Waitemata District Health Board with the help of pharmacy to raise awareness about different insulin preparations and also conduct a review of insulin errors and concerns during 2009. Pharmacists record all medication errors on a database. The number of errors recorded is dependent on the level of pharmacist participation on post-acute ward rounds. The authors analysed the insulin errors recorded from January 2009 to January 2010, relating to prescribing, administrating and documentation.

They felt that the errors analysed reflect the majority of events. Seven cases were identified where patients were given Humalog instead of a Humalog Mix (25 or 50), and one when a patient was given Humalog instead of Humulin 30/70. Most of them were recognised early with adverse events prevented, though in 2 cases significant hypoglycaemia occurred. Common insulin errors included: insulin not being charted when known to be on insulin, errors of dose and timing, GIK transfer errors (stopping the GIK without usual/new regimen being charted), and omission of insulin from discharge scripts.

The authors conclude that enhanced awareness about different insulins including Humalog Mix insulins, accurate medicine reconciliation at admissions and greater involvement of the diabetes team should improve patient safety where insulin prescription and administration is concerned. In view of the shortage of diabetes nurse specialists, they see the hospital pharmacists as an important resource to reduce insulin errors. Many diabetes patients themselves may be able to manage their insulin better than hospital staff. They go on to say that a repeat review by the pharmacy after six months will hopefully demonstrate a positive impact of updated educational resources and information.’ (www.hiirc.org.nz/page/20624/insulin-errors-in-a-hospital-setting-abstract/?q=McNamara&highlight=mcnamara§ion=10538).

This included devising a new chart for use in the inpatient setting to determine eligibility for self-administering insulin. A revised version is in development.