Summary
Insulin prescribing and administration errors in hospital cause significant risk. The paediatric diabetes team worked together with the pharmacist and paediatric unit staff to design and produce an insulin prescription drug ‘insert’ for in-patients that can be attached to each individual’s existing drug chart. The aim of this was to aid the prescription and administration of insulin injections, ensuring they are given correctly and safely, thereby reducing insulin drug errors and improving patient safety. There has been a 50 per cent reduction in errors with the administration of the insulin, including no missed doses due to unprimed pens and no over corrections.
Results
The evaluated results from the initiative are extremely positive. There has been a 50% reduction in insulin administration errors, no missed doses as a result of insulin pens being un-primed and no over-corrections. Staff feedback from the diabetes unit highlights the insert sheet’s ease of use and they emphasise that it has helped build their knowledge and confidence of safe insulin prescribing and administration.
When any member of the paediatric diabetes team reviews the patient and current prescription regime, all relevant information is presented on a simple, clearly understood sheet, allowing for easy interpretation of the data and making changes of management much more straightforward.
Challenge
Insulin prescribing and administration errors in hospital create a significant risk. Insulin safety has been a hot topic for some time and insulin safety training is now mandatory across the NHS. The health service offers regular education to both junior doctors and nursing staff on the safe use of insulin and diabetes management and carbohydrate counting but this knowledge can be difficult to put into practice.
Busy shifts, higher risk patient groups, limited experience and a drug chart that is poorly designed for insulin prescriptions are all contributory risk factors. For example, different elements of the insulin prescription can appear on different pages of the drug administration chart and there may be no easy way of prescribing a variable dose.
At Imperial College Healthcare NHS Trust, staff support patients with carbohydrate counting because increasing the dosage of insulin to correct high blood glucose levels increases room for error.
The Trust has a low admission rate for paediatric diabetes patients so ward staff are relatively inexperienced, which again increases the risk of mistakes.
Objectives
With the ambition of maximising patient safety by reducing insulin administration errors, the objective was to encourage good practice among all ward staff in the management of insulin injections from dose decision, insulin type and timing, through to administration technique and accuracy.
This was to be achieved by designing a prescription insert page that would guide good practice. The project needed to involve the whole team in design and implementation, to adapt existing prescribing systems to make implementation as easy as possible and to inspire a trusting relationship between staff and patients.
All common insulin drug errors were reviewed, including priming insulin pens and ensuring that they worked. It also considered the over-correction of high Bg levels because different parts of the drug chart were used for different insulin doses.
Solution
Staff on the paediatric unit were asked what they thought would improve practice and meetings were held with the lead pharmacist of the Trust and adult diabetologist (who sits on the medicine management committee) to ensure that any new drug administration chart would be fit for purpose.
An insulin drug insert sheet was designed and trialled, a process that was repeated eight times until the insert had only positive feedback and staff found it easy to follow and use. It was taken through the Trust’s clinical governance systems and was approved by the Medicines Management Committee in March 2013 for permanent use.
It would be effective in any unit that uses the basal bolus fast-acting insulin; carbohydrate counting for meals and snacks, a correction factor for high blood glucose levels, and hypoglycaemia corrections. The insert allows all the prescription details to be displayed on one sheet, which offers immediate access to all the key information.
Evaluation
Safe practice in the prescription and administration of insulin should be paramount in any environment in which diabetes patients are supported. In any system managed by people, errors can only be minimised, never eliminated. But it remains the continuing responsibility of all health care staff to learn from mistakes – particularly in areas of practice where history teaches us they are more likely to occur – and do everything possible to reduce their incidence and impact.
This insulin prescription insert sheet is the result of knowledge and insight acquired over time that demanded a better and safer patient experience. And although this initiative was developed in a paediatric unit, it can be used in any environment, including the community, for anyone treated with fast-acting insulins.
Imperial College Healthcare NHS Trust would be happy to share the design of this insert as long as its provenence is acknowledged.
Impact
There is a demonstrated improvement in patient safety and continuing reduction of drug administration errors for fast-acting insulins. The initiative is capable of being adapted by any similar unit and the Trust’s adult diabetes service is currently reviewing how the sheet may be adapted for its own use. The insert sheet is to be presented at the North West London Diabetes Network and at the Neonatal and Paediatric Pharmacists Conference in November 2013.
Fewer insulin drug administration errors will inevitably reduce overall length of stay, with an associated likelihood of significantly reduced costs. It also helps build confidence between patients and staff, and encourages patients to self-manage their condition, having acquired the habits of good practice and safety.
