Insulin Medication Error Reduction: A Quality Improvement Initiative

Abstract

This study describes a multidisciplinary approach to reducing insulin medication errors. In 1998, a medication error analysis at our institution demonstrated that insulin was the top drug associated with medication errors. A collaborative continuous quality improvement initiative was undertaken to develop recommendations for reducing insulin medication errors. Multidisciplinary root cause analysis revealed that during order prescribing and transcribing, the abbreviation of “u” for units—combined with the lack of a formal education program for physicians on appropriate use of abbreviations—was a major contributing cause to insulin medication errors. An extensive multidisciplinary education program was undertaken to target insulin orders for medication error reduction. To date, compliance with prescribing insulin orders within guidelines has increased from 30% to 74%, and compliance with transcribing insulin orders within guidelines has increased from 36% to 83%. This collaborative project increased awareness of insulin medication error causation and will be used as a template to reduce other types of medication errors.