Category: Professional Posters
Purpose: Medication event reporting allows for identification, resolution, and prevention of serious safety events as well as tracking and trending to identify opportunities for improvement. High alert medications, such as insulin, bear an increased risk of causing significant patient harm when used in error. The purpose of this project is to complete a robust review of medication event reports related insulin to identify trends and recommend action steps to improve patient safety.
Methods: The healthcare organization's National Medication Safety Team reviewed insulin events entered through the electronic event reporting system from January 1, 2019 through March 31, 2019. These events were analyzed and grouped by the medication use process in which the event occurred. Trends were identified and presented to nursing, physician, and pharmacy leaders in addition to frontline staff to aid in identifying potential risk mitigation strategies. In addition to review of insulin events, the National Medication Safety Team completed site assessments throughout the health ministries where the Institute for Safe Medication Practices High-Alert Medication Assessment for Insulin was completed. This assessment also identified opportunities for improvement which were incorporated into the review and recommendations.
Results: A total of 220 events were reported, of which 41% were near misses. Analysis of the data revealed that most events originated during the administering and prescribing phases of the medication use process. The most common type of insulin involved in reported events was insulin aspart, followed by insulin detemir, and insulin regular. Most of the events reported were classified as low severity errors with no harm to the patient. Reports associated with administering included providing higher doses than prescribed, dose omissions, and duplicate or incomplete orders. Higher severity events were associated with administering a higher dose than prescribed, medication reconciliation, or unpreventable adverse drug reactions. Contributing factors identified in many of the events include human factors such as failure to comply with policy or protocol, lack of attention, distraction, and miscommunication during handoff. Several risk mitigation strategies were identified. These included clinical decision support enhancements to aid in limiting available routes of administration and decreasing duplicate orders, implementation of glucometers with wireless technology or docking stations to decrease handoff miscommunication, ensuring appropriate order sets are available and implemented for rescue agents, basal, correctional insulin, and hyperkalemia treatment, as well as implementation of double checks for intravenous insulin administration.
Conclusion: Many risk mitigation strategies were identified through this multidisciplinary review of insulin events. The National Medication Safety Team will work with their respective ministries to ensure successfully adoption of these safe practice recommendations. A repeat analysis of medication events in 6-12 months will be completed to monitor for improvements.