A multi-system approach to reducing insulin errors

Abstract

Background

Insulin prescribing and administration errors are consistently high with respect to hospital in-patients. There is no straightforward solution to the problem as there are multiple causative factors and system failures. We describe the implementation of a multi-system approach which looks at changes across the board to avoid the risk of serious harm in a teaching hospital setting.

Methods

Organizational level changes included addressing the development of a culture of safety and promoting management buy in. Clinical level changes relate to the labelling and storage of insulin and the provision of accessible information for clinical staff in several different formats. Patient level changes were directed at improving the prescription charts with their own specific insulin section as well as empowering patients to retain the control of their own insulin administration.

Results

Following the initial phase of the project the number of clinical incidents relating to insulin administration and prescribing increased by 18%.

Discussion

The surprising initial outcome was felt to reflect an increased awareness of the issues surrounding insulin problems and the fact that they were previously under-reported. The project has had strong support and good feedback from a wide array of healthcare professionals within the hospital trust. The national diabetes in-patient audit will allow an opportunity for further analysis and a longer time frame for the multi-system changes to bed in.