Category: Federal Forum Posters
Purpose: The institution’s interdisciplinary Medication Event Team meets weekly to review anonymously reported medication errors. Errors are categorized as actual events that reached the patient, or near miss events that were caught prior to reaching the patient. During the previous year, the team noted an increase in the number of near miss and actual medication events related to inpatient utilization of concentrated regular insulin U-500. Given the heightened risk for serious harm associated with erroneous use, steps were taken to introduce standardized procedures for ordering, preparing, dispensing, and administering concentrated regular insulin U-500 to enhance patient safety.
Methods: As part of the Medication Event Team review process, the reported errors are analyzed and scored using the Safety Assessment Code as recommended by the National Center for Patient Safety. All medication events reported between 4/1/2017 and 3/31/2018 were reviewed; medication events involving concentrated regular insulin U-500 were assessed in more detail. Using event descriptions, medication events were characterized as errors of either ordering, administering, or dispensing, and a process flowchart was created to include all relevant steps from the patient admission to administration of concentrated regular insulin U-500. Medication event information guided the development of a root cause statement and associated action plans to enact systematic improvements to prevent recurrence and improve patient safety.
Results: There were 424 medication events during the time frame of 4/1/2017 to 3/31/2018, of which three were associated with concentrated regular insulin U-500 in the inpatient setting. The events were variable with respect to characterization, and were suggestive of systematic vulnerabilities in the ordering, preparing, and administering of concentrated regular insulin U-500. To address the variability, checklists were created for each service involved in the inpatient process. An ordering checklist was created for physicians, a preparation and dispensing checklist for pharmacists, and an administration checklist for nurses. Additionally, an inpatient pharmacy dispensing log and independent pharmacy double-check of all concentrated insulin orders were implemented for beneficial redundancy. In coordination with Nursing Education service, inpatient nurses were given an educational in-service regarding concentrated regular insulin U-500 to enhance knowledge and promote awareness.
Conclusion: Through identification and evaluation of near miss and actual concentrated regular insulin U-500-related errors, the Medication Event Team implemented systematic and standardized process improvements to optimize patient safety and avoid potential medication events.
Christopher Siegler– PGY2 HSPA Pharmacy Resident, Jesse Brown VA Medical Center, Chicago, IL