ASHP 08: Organizational challenges to insulin safety: it's not just a pharmacy problem

December 7, 2008

In this forum, Frank A. Federico, RPh, content director for the 5 Million Lives campaign being conducted by the Institute for Healthcare Improvement (IHI) in Cambridge, Massachusetts, opened by asking the question: "What keeps you up at night when it comes to insulin safety?"

In this forum, Frank A. Federico, RPh, content director for the 5Million Lives campaign being conducted by the Institute forHealthcare Improvement (IHI) in Cambridge, Massachusetts, openedby asking the question: "What keeps you up at night when it comesto insulin safety?"

Federico listened as audience members listed their concerns: "Itmakes me nervous when nurses mix insulin drips when there is nopharmacist present"; "I see numerous opened vials of insulin-withvarying dates-all around nursing units"; "Everything aboutU500."

All these comments are examples of things that happen atdifferent points in the system, he said. "Insulin safety is asystem problem, not a hospital pharmacy problem. So whilepharmacists may only be seeing one piece of the puzzle, [thequestion we address here today is] how can you be leaders ininsulin safety?"

He then asked what works well about insulin safety. Answersincluded technology such as barcode readers, making drips in thepharmacy, and limiting who has access to insulin vials. Also, "standardization is one of the key concepts in insulinsafety," noted Federico. He went on to explain how the IHIcampaign for 5 Million Lives "focuses on high-alert medicationsincluding insulin, anticoagulants, narcotics/opiates, andsedatives. These are the big four. We help hospitals focus on theissues with these meds through our ‘global trigger tool.'"Federico explained that this is an abbreviated chart review tool."We found that about 50 out of 100 admissions had some kind ofharm," he said. "If you were a patient, you don't want that tohappen to you. For patients, 50% [of the instances of harm] aredue to meds, and the four above are the leading candidates. Wefocused on anticoagulants last year; the next focus isinsulin."

Federico outlined three principles that can enhance insulinsafety in a system:

  • Prevention: design processes that make it hard to do thewrong thing;
  • Detection: design a strategy so that harm can beidentified more quickly; and
  • Mitigation: determine what steps can be taken toprevent harm, or if harm has occurred, to prevent the harm frombecoming more serious.