Embarking on what has turned out to be a multi-year journey, Great Plains Regional Medical Center (GPRMC) staff tackled the issue of reducing insulin errors. Based on a review of the hospital’s data, they set their goal at a 50 percent reduction in insulin errors.

The facility chartered an insulin safety team to look at the use of insulin. The team consisted of individuals from nursing, pharmacy, lab, and administration. In 2006 they identified thirty-five errors involving insulin with four resulting in patient harm. Several factors contributed to these errors. They found that they had multiple brands of insulin in use. This resulted in order entry and administration errors. A lack of standardized insulin administration and hypoglycemia protocols also contributed to the problem. It was noted that previous implementation of a policy for a double-check of insulin at the bedside was not consistently being done which also contributed to the error rate. Mandatory educational sessions regarding insulin safety were well attended, but did not result in a corresponding decrease in harmful insulin errors. Another issue identified was the fact that patients, when admitted, may not have their insulin with them and could not accurately tell the staff the type of insulin they used.

To address the issue of multiple brands of insulin in use, the formulary was reduced to five types of insulin. An added benefit is that they are expanding this concept to other drugs in their pharmacy; for example, they are reducing the number of statins that are available to no more than five.

To assist with the medication reconciliation process, a visual aide containing pictures of multiple varieties of insulin was developed and distributed to the clinical areas to be used during the admission process. This picture display helps the patients and their families correctly convey to the staff the type of insulin they are using at home. No errors have been identified to date with the admission medication reconciliation process since implementing this procedure.

To assist with the requirement of an independent, double-check when insulin is administered, they turned to their electronic medical record. Their software system allows for an electronic signature by the person completing the independent, double-check. The system then provides a daily ‘uncharted medication list’ which is provided to all clinical areas each shift. A decrease in errors has been documented as a result of this real time feedback to the clinical areas.

Another issue presented itself as GPRMC worked on the issue of safe insulin administration. In addition to the difficulty on the part of patients in correctly identifying the type of insulin they used, staff also noted errors with patients using multi-dose vials and errors related to mixing insulin. To address these issues, GPRMC implemented the use of insulin pens. The pens provide 300 units versus the usual 1,000 units per vial. This created less waste for the patient and the facility and has resulted in a cost savings to both. To assist staff, a Guide was developed which lists each type of insulin, its source and color, injection time, risk time for hypoglycemic reaction, action, start of action, peak action and duration for each of the five types of insulin that are stocked in their pharmacy.

GPRMC was able to achieve their goal of a 50 percent reduction in insulin errors by the 4th quarter of 2007. There were a total of eleven insulin errors with only one resulting in patient harm. All insulin errors continue to be monitored by the medication safety committee.

As a result of their work with insulin errors, GPRMC identified another issue—that of maintaining the patient’s blood glucose levels at an acceptable range during their hospital stay. Evidence-based research indicates that hyperglycemia increases mortality, prolongs a patient’s length of stay, and increases the risk of complications for patients in acute care settings.

A regular insulin drip protocol had long been utilized house-wide, but internal review showed that GPRMC was not achieving targeted blood glucose levels. To correct this problem, they decided to initiate a two-year trial in the intensive care unit in an effort to achieve glycemic control within the critically ill patient population. Work on this issue began in January of 2008. A hypoglycemic protocol was developed and applied in the ICU. This pilot project was quickly successful in reducing ICU patient’s blood glucose to the target range of 70-110 mg/dL. The project was then rolled out throughout the hospital. Based on the organization’s average glucose levels, the team established a goal of maintaining their patient’s blood glucose levels at 150 mg/dL. The team implemented house-wide education for the medical, nursing and pharmacy staff regarding utilization of the Intensive Insulin Drip Protocol. They have standardized to one insulin drip protocol which is now used throughout the facility. GPRMC has been able to reduce their facility wide average blood glucose level to 155 mg/dL and continues to work to reach their target.
 

Reference:

• Society of Hospital Medicine (SHM) Workbook for Improvement: Improving Glycemic Control Preventing Hypoglycemia and Optimizing Care of the Inpatient With Hyperglycemia and Diabetes

• Safe Use of Insulin In Hospitals