Eliminating insulin errors: R.Ph.s share tricks

March 20, 2006

Not only do 11% of serious medication errors involve insulin misadministration, but the same errors seen today have been documented at least as far back as 1975. These were but two of the points Matthew Grissinger, R.Ph., used to emphasize the importance of health-system insulin safety during February's ISMP teleconference, "Preventing Errors with Insulin: A Multidisciplinary Approach."

Not only do 11% of serious medication errors involve insulin misadministration, but the same errors seen today have been documented at least as far back as 1975. These were but two of the points Matthew Grissinger, R.Ph., used to emphasize the importance of health-system insulin safety during February's ISMP teleconference, "Preventing Errors with Insulin: A Multidisciplinary Approach."

The value of communication and education was echoed by Maria Summa, Pharm.D., assistant director for clinical programs for the Department of Pharmacy at Saint Francis Hospital and Medical Center, Hartford, Conn. "We've done a full-scale educational effort. For example, the nurses received many months of detailed in-services on the types of insulin, which ones are common to our formulary, which ones patients might be coming in on, and the main errors related to all those insulins."

Grissinger was asked which strategies he considered primary to controlling insulin errors. No. 1, he said, is to have a strict formulary. "By reducing inventory to the most basic insulins you need, you don't have to deal with so many look-alike names and look-alike packaging."

Summa said that about 18 months ago, Saint Francis set up an insulin task force, and one of its targets was to standardize insulin products on its formulary. "We now have only one brand of rapid-acting insulin, one analog, one intermediate-acting, one basal long-acting, and one mixture product." The task force also narrowed insulin-drip protocols down to four populations-medical/surgical, critical care, antepartum, and intrapartum-so there "weren't so many protocols floating around that had conflicting information."

Davern added that the task force has standardized insulin infusions at one unit per ml. "If someone's getting 50 mls an hour, he/she is getting 50 units per hour, which has reduced transpositions of rate and concentration, a frequent infusion error."

Although many of the errors illustrated during the teleconference were a result of illegible handwriting and faxes or misunderstood verbal orders-errors ostensibly eliminated with computerized physician order entry-Mary Inguanti, R.Ph., Vice President of Operations at Saint Francis, cautioned that with CPOE "you have different types of errors, and we've taken steps to minimize the ability to make an aberrant selection with the lightpen or the mouse."

For example, Summa explained, "within the past couple of months we've rearranged the way insulin appears in our medication drop-down ordering window. When staff members order insulin, a pop-up screen now reminds them they're ordering a high-risk, high-alert medication and that they need to input their orders exactly as they intend them to be. It notes whether an insulin is rapid-acting or long-acting."