the omission of the medication for glycemic control upon discharge was the result of medical error. The frequency of readmission postdischarge is directly related to such errors upon discharge. The “hand-offs” in care transitions are among the events at highest risk for errors.
Dispensing Errors
Dispensing insulin can be a complex process and can vary widely from one institution to another. The trend, correctly so, is to have the hospital pharmacy solely responsible for the labeling, storage, and dispensing of the insulin to the nurse who is to administer the dose, whether it be IV or SQ. The pharmacist usually has the responsibility of being sure that the correct insulin dose is in the IV solution that is to be administered, and in the single dose pen or syringe that is to be sent to the floor, but the accuracy of the dispensing process is not guaranteed. As with all aspects of the processes of care, it is helpful to keep metrics on the performance in the pharmacy regarding errors of all types and to provide timely feedback so workflows can be changed to improve performance.
Storage Errors
Storage of insulin is an issue in the hospital setting and can be the source of serious errors. There are many types of these errors. Some hospitals, for example, may use U-500 insulin as well as the standard concentration, U-100 insulin, and may store the U-500 insulin vials in the clinical area, at the nurses’ station, for the convenience of the staff. This error type can be remedied by storing U-500 insulin in the hospital pharmacy and dispensing it only with bar-code labeling that is specific for a patient on the clinical unit. Some insulin pens and vials, however, may be stored on the unit in a secure drawer, for the individual patient. The use of double-checks and bar coding of all insulin-containing pens or vials or syringes is highly recommended to reduce risk of patient injury.
Administering Errors
After prescribing and transcribing errors, the administration of insulin is perhaps the next most frequent type of error, and it is certainly the one that is most visible. Unfortunately, in many hospitals, the important function of administering the dose of insulin is not done without frequent errors. A recent review of insulin therapy error data from the British National Patient Safety Agency showed the high frequency in which patients received a wrong dose, strength, or frequency of insulin.2 They also found that insulin doses were commonly omitted or the wrong insulin product was used.
Prefilled insulin IV containers and insulin syringes prepared by the pharmacy may reduce the burden somewhat, but there are many potential sources of error. The nurse needs to double-check to ensure that the ordered insulin dosage is correct. In addition to checking the insulin type, route, and dose, time may have elapsed since the order was given, and understanding whether the order for this dose of insulin is still appropriate for the patient is important. Communication between nurses and physicians is essential to the safety of insulin administration. In many discussions on errors of insulin therapy, the role of the nurse in catching errors or potential errors made by others is overlooked, but in one study, 86% of the errors that were avoided were found by the nurses.37
New technologies may present special challenges as well. Although insulin pens have been widely used in hospital settings, the accuracy of pen delivery depends on the use of proper technique.38 For example, some pens will not deliver the full dose of insulin unless the needle is held in place for 6 sec after administering the dose. If the pen is removed before 6 sec has elapsed, the full dose is not injected into the site. Likewise, although needle guards are designed to prevent needle-stick injuries, when unfamiliar with the type of insulin pen, nurses not infrequently suffer needle-stick injuries despite these guards.
Smart IV pumps are IV infusion pumps designed not to allow infusion errors by prohibiting rates of infusion outside of what the pump memory has programmed to be the limits of safe infusion for that individual drug. They are a technological advance and have been shown to reduce some types of errors, but even these smart pumps may present complexities for the health-care provider unfamiliar with their proper function and errors may result.
Glucose Monitoring Errors
The ASHP recommendations regarding glucose monitoring emphasize the training of those who perform the glucose monitoring and the establishment of minimum frequencies of glucose monitoring: no less than every 4–6 h if a patient is on insulin but as often as hourly with insulin infusions. These recommendations focus on the need to document and communicate the results of glucose monitoring to the clinical team and to provide both critical values on an urgent basis and alerts to notify appropriate caregivers when there is an increased risk for hypoglycemia. The ASHP also emphasizes the need to verify POC glucose values when a critical result is noted. They also recommend the need for observation of the patient if self-monitoring is allowed. These are all sound recommendations.39
Recommendations for Change
Systemic Recommendations
• Establish a culture of safety with specific attention to assuring patient safety throughout insulin therapy. The need for timely and effective communication, coordination, and teamwork is key. The environment should promote a nonpunitive learning environment.
• A multidisciplinary management team should be formed and given authority to manage or comanage critical clinical problems or emergencies in glycemic control. They should have an ability to provide education and consultation for hospital staff, health-care providers, and patients as resources allow, and to advise the hospital administrator on suggested improvements in glycemic control.
• The hospital administrator should seek input from the glucose management team and other relevant people or groups regarding the need for additional staffing or training or other resources relevant to improving diabetes care and reducing errors in insulin administration. The hospital administrator should strongly support a culture of safety at the institution and focus care staff on clinical goals, not on nonclinical goals.
• The ASHP professional practice recommendations for the safe use of insulin in hospitals should be incorporated into the hospital’s policies and procedures. Double checks should be the norm for each of the steps in insulin therapy.
• An EHR with capabilities of CPOE should be instituted hospital-wide and all parts of the hospital should use either the same system or one that communicates transparently with the main EHR. Decision support tools and forcing functions, if carefully validated, may be used to improve safety of insulin therapy.
• Hospital-wide insulin order sets should be made available for each of the clinical situations in which errors in insulin use may occur.
• Processes of care for each step in the provision of insulin therapy, from prescription to administration and monitoring, should be written unambiguously in preprinted, approved, evidence-based orders and should be reviewed at least annually to ensure that they are being used correctly and remain valid.
• The quality of POC glucose monitoring should be a high priority. The POC glucose meter performance should be tested at regular intervals under the direction of the hospital clinical laboratory. All users of the POC glucose monitors should receive thorough education and must regularly pass proficiency testing. POC meters or strips that do not meet the new FDA standards for POC meters used in clinical units should be replaced.
• The hospital should provide guidelines delineating the strengths and weaknesses of the POC meters, and only POC meters that can demonstrate accuracy at the new FDA standard should be allowed in operating rooms or intensive care units. The hospital should consider whether a POC blood-gas analyzer using arterial blood samples for more optimal POC glucose measurement should be made available for use in critical care areas.
• Metrics for glycemic control should be obtained on a periodic, regular basis, and feedback should
