to national standards should be performed and a continuous quality improvement strategy followed. When problem areas emerge, nonpunitive steps to remedy the problem should be provided.
• Extensive education programs that provide a general understanding of diabetes care standards in the inpatient setting and specific staff responsibilities should be provided. Proficiency standards should be established. Health-care providers and staff should be tested initially and annually to ensure continued proficiency. Education programs should be tailored to the learning styles and strengths of the intended audience.
• All never-events should be given a root-cause analysis and efforts to educate and correct the errors should be undertaken.
• Encourage education of all staff, including ancillary staff such as transportation staff, on safety in insulin therapy.
• Educate nurses on the new technologies they will be responsible for, particularly POC glucose monitoring systems, smart pumps, and other new technologies used in the care of the patient with diabetes.
• Perform studies on a regular basis to ensure that the interventions to improve insulin safety are working as expected. Use objective metrics such as test scores and timely feedback of near misses and errors to obtain a more complete assessment of what is actually taking place in the hospital.
• Checklists should be developed for each provider or specialized care unit so the key steps in their tasks in insulin therapy can be clearly noted and always performed in the correct sequence.
Recommendations to Reduce the Frequency of Diagnostic Errors
• Utilize system-related factors to decrease diagnostic errors, as for example, to provide timely feedback on diagnostic studies that are needed to verify a diagnosis, both radiologic, laboratory, and other consultant-generated studies.
• Educate clinicians as to common pitfalls of clinical reasoning and provide back-up checks on their own diagnoses and real-time team discussions of the patient’s clinical status.
• Encourage clinicians to consider whether their initial diagnoses are correct or whether new information will alter their initial judgment. Premature closure is the most common cognitive error that leads to faulty diagnoses.
• Provide timely consultative expertise to the responsible provider of the diabetes care.
• Encourage the use of diagnostic simulations and case studies to provide training and education and review to improve diagnostic accuracy.
• Transitions of care must be done with the highest level of mindfulness because of the high error rates, particularly with insulin therapy.
• Errors that cause injury should be studied in depth to learn where processes of care and education need to be modified.
• Encourage feedback from patients and families regarding insulin therapy and errors, and incorporate that data in reports.
Conclusion
This chapter discussed different types of errors in insulin therapy and provided examples of each category. Unfortunately, prescribing errors, transcribing errors, dispensing errors, storage errors, administration errors, and monitoring errors are still far too common. The systemic causes of error are most important, because many of the remedies that can be done at this level are much more likely to have the largest impact on making insulin therapy safer. It is also important to look at the performance of individuals involved in the care of the patient receiving the insulin therapy, if we are to create an environment that will always protect the patient from harm and also reduce the number of noninjurious and latent errors. Cognitive psychology helps us better understand the different ways in which our cognitive processes make us vulnerable to error and to help us avoid our own diagnostic errors—the kinds of errors most difficult for the individual to discover and most likely to cause an injurious error. One of the strengths of a culture-of-safety approach is the constant back-up checks and feedback provided to the clinicians, which greatly reduces the risk that a diagnostic error will go undetected. Involvement of the patient and their family in their care is crucial in reducing insulin errors. A culture of safety should strive to always include an informed patient and their family as a central aspect of a team approach in the provision of insulin therapy in the inpatient setting.
Human factors are important to consider in the effort to reduce errors in insulin therapy. Even a highly skilled and knowledgeable provider of care may make a serious error if their sequence of steps during clinical care is interrupted, and these errors often are not noticed when rushed. Yet, along with a propensity for cognitive errors, humans have remarkable cognitive flexibility. A successful culture of safety must include back-up checks to discover these human errors and use the cognitive flexibility of the team members to create an environment that has patient safety as the highest priority.
Finally, the best institutions will need to consider the danger of burdening the clinical team with nonclinical priorities. The more the clinical team is rewarded primarily for nonclinical priorities, the harder the task becomes for making insulin therapy safe for every patient.
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