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INSULIN ADMINISTRATION
Spring 2014, N362 Leeah Javier, Tiare Palimoo, Jessica Lafaele, Diane Nichols and Brandi Anastacio
http://www.youtube.com/watch?v=vxrkQOQLSU8
out of 1,000 people age 18-84 are diagnosed with live in Hawaii, with a projection of at least 26% of persons with
The American Diabetes Association states over 113,000 1 out of 3 persons by 2050 Center for Disease Control and Prevention estimates that diabetes require insulin to maintain glucose levels
The Institute for Safe Medication Practice (ISMP) has named Insulin as one of the five HIGH ALERT medications, due to its high risk of causing injury if misused.
During a period of one year, there were a total of 4,764 insulin errors reported to the Medmarx database. Just over 6.5% of these errors caused harm to the patient. Thats 310 people!
fatal
A dialysis technician inadvertently administered insulin instead of heparin to a patient in the dialysis unit of a hospital. Insulin was kept as floor stock in this unit. The patient suffered fatal neurological damage due to decreased glucose levels. 2003
Hospital Physician orders 8 units of insulin for 57 year old female patient, experiencing complications during rehab. Which is transcribed as 8.0 units. Nurse on rehab unit administers 80 units of insulin. Patient dies due to complications and Hospital, transcriptionist and nurse are sued for $140 Million. New York, 2013
Administering
Monitoring
Failure to appropriately monitor for insulin effects and adjust dose accordingly
Preferred Outcomes:
Errors related to administration will decrease by at least 50%. This will be monitored through a reporting system and addressed monthly, with the use of a bar chart, pie chart and flow chart.
ACTION STEPS: DO
WITH RECOMMENDATIONS
- Store insulin and administration devices in a secure fashion and segregated from other medications. - Ensure insulin use is linked directly to patients nutrition status. - Implement a double check system (two nurses) during preparation of insulin. - The 5 Rights of Medication Administration: Right Patient, Right Medication, Right Dose, Right Route, and Right Time.
- Provide mandatory training before administrating insulin pen devices. - Prepare chart that lists all insulin products used in the facility. - Staff members should receive clear instructions about how to proceed if they encounter problems, and real-time support should be accessible at all times. - Provide ongoing education about insulin products and methods of delivery.
All data will be periodically reviewed to assess for errors and possibility of improvement. When goals are met based on implementations, then the process may be presented to the rest of the facility, in order to restructure their processes accordingly and improve our quality outcomes. ***The PDCA process should continue until goals are surpassed for each clinical area.
RESOURCES
American Diabetes Association. (n.d.). Retrieved from http://www.diabetes.org/in-my-community/local-offices/honolulu-hawaii/ Centers for Disease Control and Prevention. (2009). National health interview survey. Retrieved from http://www.cdc.gov/diabetes/pubs/pdf/factsheet11_figures.pdf Cobaugh, D. J., Maynard, G., Cooper, L., Kienle, P.C., Vigersky, R., Childers, D., & Cohen, M. (2013). Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel. American Journal of HealthSystem Pharmacy, 70(16), 1404-1413. doi: 10.2146/ajhp130169 Mattox, E. (2012). Strategies for improving patient safety: Linking task type to error type. American Association of Critical Care Nurses, 32(1), 52-60, 78. doi: 10.4037/ccn2012303 Rubin, J. D., Russell, L. A., & Cohn, B. (2013). Transcription error results in medication dose that is fatal and $140 million verdict. Healthcare Risk Management, 1-3. Santell, J., Hicks, R., & Protzel, M. (2003). RN news watch: drug update. Error watch: is your patient a diabetic? Watch that insulin dose!. Rn, 66(10), 92. The Joint Commission. (1999, November 19). High alert medications and patient safety (11). Retrieved from http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_11.htm?print=yes U.S. Department of Health and Human Services. (2013, September 8). Diabetes national data. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/nationaldata.aspx?topicId=8
Ward, L. G., & Aton, S. S. (2011). Impact of an interchange program to support use of insulin pens. American Journal Of HealthSystem Pharmacy, 68(14), 1349-1352. doi:10.2146/ajhp100535