Faculty. Disclosures. Prescribing. A Multidisciplinary Approach to Preventing Medication Errors Associated with Insulin Therapy. Learning Objectives

Transcription

1 A Multidisciplinary Approach to Preventing Medication Errors Associated with Insulin Therapy Faculty Matthew Grissinger, RPh, FISMP, FASCP Director, Error Reporting Programs Institute for Safe Medication Practices Manager, Medication Safety Analysis PA Patient Safety Authority Horsham, Pennsylvania Presented in partnership with the ICHP Annual Meeting Disclosures Learning Objectives Matthew Grissinger, RPh, FISMP, FASCP: Spouse s Employer Johnson and Johnson Describe common preventable adverse events with insulin therapy and their causes Illustrate the importance of preventing errors through improved order communication, administration, monitoring, and patient education Develop a standardized approach to the use of insulin throughout the medication use process Describe strategies healthcare practitioners can use to prevent medication errors and improve insulin therapy for the effective management of diabetes Technician Learning Objectives Describe common preventable adverse events with insulin therapy and their causes Illustrate the importance of preventing errors through improved order communication, administration, monitoring, and patient education Develop a standardized approach to the use of insulin throughout the medication use process Describe strategies healthcare practitioners can use to prevent medication errors and improve insulin therapy for the effective management of diabetes Prescribing 1

2 Barriers to Effective Communication of Insulin Orders Sliding-Scale Insulin Handwritten orders Dangerous abbreviations Verbal orders Look-alike names Sliding-scale orders Ambiguous orders Hold orders Standardize Order Communication Use standardized insulin protocols ADA Guidelines 2014 Use standardized order forms List specific products Include prompts to enter dose Incorporate times and meals Standardized correction scales Monitoring parameters Reversal agents Trence DL, et al. J Clin Endocrinol Metab. 2003;88: Prescribing U-500 Insulin An endocrinologist wrote an order for 25 units of U- 500 insulin to be given in the morning In reality, he wanted the patient to receive 125 units Since each ml of U-500 insulin contains 5-fold more insulin than U-100, he was actually citing the 25 units marking on the U-100 insulin syringe scale Patient Assessment, Administration, and Monitoring 2

3 Patient Assessment: Before Administration Prior to the administration of subcutaneous insulin, practitioners (ie, nurses, nursing assistants) perform an assessment of the following: Bedside POC blood glucose value (finger stick) Symptoms of HYPOglycemia Symptoms of HYPERglycemia Nutritional status (eg, NPO, receiving enteral or parenteral nutrition, last oral intake) Changes in the patient s condition (eg, infection) Changes in the patient s medication regimen (eg, addition or discontinuation of a medication that may impact blood glucose levels [eg, corticosteroid]) NPO Status A patient with diabetes on continuous enteral feedings was also receiving subcutaneous NPH insulin, 24 units BID, to control elevated glucose levels. The feedings were then held for a CT scan but no one discontinued the insulin By the time the BG was checked again, it measured only 26 mg/dl BG = blood glucose. POC = Point of care; NPO = Nil per os/not by mouth. ISMP. MSA! 2003(Sept 4):8(18). Insulin orders on MARs MAR = Medication Administration Record. Wrong Dose Errors Due to Wrong Blood Glucose Values Monitoring 12.9% of the wrong-dose events involved breakdowns with obtaining and/or communicating patients blood glucose values Specific problems include: Reporting an incorrect value Confusing the patient s weight for his or her blood glucose level Verbally communicating the wrong patient s value Documenting the wrong result 17 Pa Patient Safety Authority. Pa Patient Saf Advis Mar;7[1]:

4 Wrong Dose Errors Due to Breakdowns in Communicating Blood Glucose Results Blood Sugar Levels or? The nurse asked the nursing assistant for the patient s AccuCheck results. The nurse was told that the blood glucose was 377. The patient was covered with 10 units of Humalog per sliding scale guidelines. When the nursing assistant wrote the AccuChecks on the bulletin board, the blood glucose of 97 was written for that patient. A nurse extern came out of patient s room at the time AccuChecks are performed. The nurse extern stated 211, and RN repeated 211, right? The nurse extern was referring to the patient s daily weight, which is supposed to be performed at 7:30 a.m. The nurse covered the patient with 4 units of regular insulin then five minutes later the nurse extern informed the RN that the patient s blood glucose level was 130. The nurse picked up a piece of scrap paper that listed several patients with a number next to each name. All of the numbers were well above 200 Assuming the numbers were blood sugar levels, she gave each patient insulin using a sliding-scale protocol Afterwards, she realized that the numbers were actually patient room numbers! Pa Patient Safety Authority. Pa Patient Saf Advis Mar;7[1]:9-17. ISMP. MSA! 2003(Nov 27):8(24). Bedside POC Blood Glucose Process for documenting bedside POC blood glucose values in a standard location that allows nurses to determine an appropriate dose of insulin and track the patient s overall response to therapy Prohibits verbal communication of bedside POC blood glucose values from staff who obtain bedside POC blood glucose values to nurses who are administering insulin How many patients are harmed with insulin in your organization? 22 Triggers Insulin Triggers An easily identifiable, focused item representing an opportunity (or clue) that may lead to an adverse event Medications, laboratory tests, patient conditions Something went wrong Effective method for measuring the overall level of harm Triggers Dextrose 50% Glucagon Blood glucose more than 300 or less than 50 Rapid response team call Possible ADE Hypoglycemia 4

5 Outcome Measures: Insulin Numerator: Number of episodes of blood glucose results (bedside and lab testing) less than or equal to 50 mg/dl Denominator: Number of inpatients who are Questions? Numerator: Number of episodes of administering Dextrose 50% to treat hypoglycemia for patients Denominator: Number of inpatients who are 5