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An initiative to reduce insulin-related adverse drug events in a children's hospital.

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Lawson SA, Hornung LN, Lawrence M, et al. Pediatrics. 2022;149:e2020004937.

Insulin is a high-risk medication and can contribute to adverse events in pediatric patients. This paper describes one children’s hospital’s experience implementing a new standardized medication administration process for insulin and the impact on insulin-related adverse drug events (ADEs). Findings indicate that implementation of a PRN (i.e., “as needed”) ordering process and clinician education decreased insulin-related ADEs and reduced the time between blood glucose checks and insulin administration.

Weight-based Medication Errors in Children.

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Farnborough, UK: Healthcare Safety Investigation Branch; February 2, 2022.

Weight-calculation errors can result in pediatric patient harm as they affect medication prescribing, dispensing, and administration accuracy. This report examines factors contributing to a computation mistake that resulted in a child receiving a 10-fold anticoagulant overdose over a 3-day period. Areas of focus for improvement include use of prescribing technology, and the double-check as an error barrier.

Adverse glycemic events and critical emergencies.

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ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.

Insulin is a high-alert medication that requires extra attention to safely manage blood sugar levels in chronic or acutely ill patients. This alert highlights look-alike/sound-alike packaging, delayed medication reconciliation, and dietary monitoring gaps as threats to safe insulin administration in emergencies. Recommendations for improvement are provided for both general in-hospital, and post-discharge care.

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

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Dornan T, Lee C, Findlay-White F, et al. Med Teach. 2021;43:1419-1429.

Health profession students are required to demonstrate competence in a variety of areas related to safe patient care. This article puts forth a recommendation to move beyond core competencies to improve patient safety and clinicians’ mutual safety.

A Sweet Case of Hidden Hydrogen Ions

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April 28, 2021

A 24-year-old woman with type 1 diabetes presented to the emergency department with worsening abdominal pain, nausea, and vomiting. Her last dose of insulin was one day prior to presentation. She stopped taking insulin because she was not tolerating any oral intake. The admitting team managed her diabetes with subcutaneous insulin but thought the patient did not meet criteria for diabetic ketoacidosis (DKA), but after three inpatient days with persistent hyperglycemia, blurred vision, and altered mental status, a consulting endocrinologist diagnosed DKA.

Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017.

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Geller AI, Conrad AO, Weidle NJ, et al. Pharmacoepidemiol Drug Saf. 2021;30:573-581.

The Institute for Safe Medication Practices (ISMP) classifies insulin as a high-risk medication. This study examines insulin mix-up errors that resulted in emergency department visits or other serious adverse events. Most cases of medication mix-up involved rapid-acting insulin. Recommended prevention strategies include increased patient education and human factors engineering.

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

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Gurwitz JH, Kapoor A, Garber L, et al. JAMA Intern Med. 2021;181:610-618.

High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.

Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education.

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Wei ET, Koh E, Kelly MS, et al. J Am Pharm Assoc (2003). 2020;60:e76-e80.

Insulin is a high-risk medication that can lead to harm if administered incorrectly. This article describes four cases highlighting the importance of providing appropriate education on injectable antidiabetic medications, common diabetes-related medication errors in primary care, identifying patients who may be at high risk and ways to prevent these errors.

Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump

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October 28, 2020

A 14-year-old girl with type 1 diabetes (T1D) was admitted to the hospital after two weeks of heavy menstrual bleeding as well as blurred vision, headache and left arm numbness. MRI revealed an acute right middle cerebral artery (MCA) infarct.

FDA advises health care professionals and patients about insulin pen packaging and dispensing.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 13, 2020.

Insulin use errors are common despite their heightened potential for patient harm. This announcement highlights labeling and storage practices to reduce dispensing and administration errors associated with individual insulin pen use.

Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center.

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Ho S, Stamm R, Hibbs M, et al. Jt Comm J Qual Patient Saf. 2019;45:814-821.

Recent guidelines from the Institute for Safe Medication Practices have warned of the risk of blood-borne disease transmission associated with insulin pen sharing in hospitalized patients and provide recommendations for safe practices. This paper describes the impact on insulin pen sharing after the implementation of safe practice recommendations (e.g., label redesign, patient-specific bar coding on pens) at a quaternary academic medical center. Institutional efforts resulted in a less frequent pen-sharing events and a decrease in latent errors found during medication drawer audits, such as retained pens after discharge and illegible or missing label.

Improving the quality of insulin prescribing for people with diabetes being discharged from hospital

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Bain A, Silcock J, Kavanagh S, et al. BMJ Open Qual. 2019;8:e000655.

Medication errors involving insulin are common, particularly in hospitals and at point-of-care transfers. Using a continuous improvement methodology, a multidisciplinary project team carried out three “plan-do-study-act" cycles to introduce locally tailored insulin discharge prescribing guidance. Adherence to the guidelines improved from an average of 50% to 99% after introduction of a poster and then checklist forms of the guidelines. This small, qualitative study in one hospital diabetes ward suggests that small iterative changes can improve insulin discharge prescription quality. A PSNet primer expands on the topic of medication reconciliation.

Duplicate Insulin Order

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March 1, 2019

Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.

Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit.

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Wong A, Rehr C, Seger DL, et al. Drug Saf. 2019;42:573-579.

Although clinical decision support is intended to improve safety, decision support alerts often result in alert fatigue and overrides. This prospective observational study examined overrides for exceeding the maximum dose of a medication in the intensive care unit. Researchers determined that insulin was the most frequent medication for which a maximum dosage alert was overridden. In almost 90% of cases, the overrides were deemed clinically appropriate. The authors conclude that more intelligent clinical decision support for medication dosing is needed to balance safety with alert fatigue in the intensive care unit. A past PSNet perspective discussed the challenges of implementing effective medication decision support systems.

Insulin pumps have most reported problems in FDA database.

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Mohr H, Weiss M. Associated Press. November 27, 2018.

Usability issues, poor design, and lack of effective instruction hinder safe use of medical equipment. This news article reports on problems associated with ambulatory use of insulin pumps submitted to a Food and Drug Administration database.

Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.

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MacMaster HW, Gonzalez S, Maruoka A, et al. Jt Comm J Qual Patient Saf. 2019;45:380-386.

Insulin is a widely used high-risk medication. This quality improvement intervention employed barcode medication administration and a standardized electronic health record–integrated workflow to successfully reduce wrong-patient insulin pen errors. The authors call for widespread implementation of medication safety improvements into electronic health records.

Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors.

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Singh A, Adams A, Dudley B, et al. BMJ Open Qual. 2018;7:e000312.

Diabetes care involves the use medications that have high risk of adverse drug events. This commentary describes a multidisciplinary plan–do–study–act initiative to develop insulin error reduction strategies and improve safety of surgical patients with diabetes. The 3-year project developed guidelines, educational initiatives, and a whiteboard system to enhance the reliability of insulin therapy in the unit.

Randomized controlled evaluation of an insulin pen storage policy.

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Gibbs HG, McLernon T, Call R, et al. Am J Health Syst Pharm. 2017;74:2054-2059.

This quality improvement intervention sought to decrease wrong-patient errors with insulin pens by storing them in locked boxes in patient rooms. Four hospital units had a formal policy change for insulin pen storage, and four units provided education to nurses about insulin pen storage. Researchers found that the policy change was more effective than education in spurring adherence to in-room insulin pen storage guidelines.

Insulin dosing error in a patient with severe hyperkalemia.

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Hewitt B, Barnard C, Bilimoria KY. JAMA. 2017;318:2485-2486.

This case report describes an insulin dosing error during hospitalization. The investigation uncovered several root causes, including lack of a standardized medication double-check. The authors note that prompt error disclosure to the patient and family was performed, and the patient required additional monitoring but experienced no further harm.

Severe hyperglycemia in patients incorrectly using insulin pens at home.

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National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. October 12, 2017.

Care devices that enable patients to administer medicines at home can have unintended consequences. This alert raises awareness of hazards related to insulin pen misuse and offers recommendations to reduce risks, such as training patients to properly use pen needles and engaging community pharmacists in verifying that patients understand appropriate administration techniques.

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