The Importance of Using Insulin Safely. Learning Objectives

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1 The Importance of Using Insulin Safely Victor Tran, PharmD PGY 1 Pharmacy Resident Ambulatory Care Diabetes Symposium November 12, 2015 Learning Objectives List the potential adverse drug events of insulin use Explain what hypoglycemia is Be able to avoid improper insulin use Recognize patient specific factors that could impact blood sugar levels and insulin use 1

2 Insulin: High Alert Medication The Medication Error Type Involving Accidents with Insulin Medication Error Type Incidents Percentage (%) Wrong dose, strength, or frequency 4, Omitted and delayed doses 3, Wrong insulin product 2, Other 6, Total 16, Cousins D, Rosario C, Scarpello J. Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency. Clin Med. 2011; 11: Insulin: High Alert Medication The Medication Error Type Involving Accidents with Insulin Degree of harm Incidents Percentage (%) Death 6 <1 Severe 12 <1 Moderate 1,042 6 Low 2, No harm 12, Total 16, Cousins D, Rosario C, Scarpello J. Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency. Clin Med. 2011; 11:

3 Insulin: High Alert Medication The Medication Error Type Involving Accidents with Insulin Degree of harm Incidents Percentage (%) Death 6 <1 Severe 12 <1 Moderate 1,042 6 Low 2, No harm 12, Total 16, Cousins D, Rosario C, Scarpello J. Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency. Clin Med. 2011; 11: Insulin: Safety Concerns Adverse Drug Reactions: Weight gain Injection site reactions Local allergic and hypersensitivity reactions Insulin Lispro. In: Clinical Pharmacology [database from the internet]. Tampa (FL): Gold Standard;

4 Insulin: Safety Concerns Adverse Drug Reactions: Weight gain Injection site reactions Local allergic and hypersensitivity reactions Hypoglycemia Insulin Lispro. In: Clinical Pharmacology [database from the internet]. Tampa (FL): Gold Standard; Hypoglycemia Definition: Low blood sugar 2015 ADA guidelines: Signs and Symptoms: Hunger Nervousness Shakiness Sweating Dizziness Confusion Crying out or having nightmares Pajama and/or sheets damp Confused upon waking up American Diabetes Association Standards of Medical Care in Diabetes Diabetes Care 2015; 38 (Suppl. 1): S1 S2. 4

5 Remember this? The Medication Error Type Involving Accidents with Insulin Medication Error Type Incidents Percentage (%) Wrong dose, strength, or frequency 4, Omitted and delayed 3, doses Wrong insulin product 2, Other 6, Total 16, Main Causes of Insulin Errors Incorrect prescription on admission Incorrect monitoring of blood glucose and dose adjustment of insulin Poor documentation of dose administration time on patients charts Duplicate dose Cobaugh DJ, Maynard G, et al. Enhancing insulin use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel. Am J Heealth Syst Pharm. 2013; 70:

6 Most Common Causes of Insulin Errors Incorrect prescription on admission Good medication history Use the Power Plans designed for Insulin Incorrect monitoring of blood glucose and dose adjustment of insulin Good coordination to measure at the correct times & document Monitor both blood glucose and hypoglycemia s/sx Poor documentation of dose administration on patients charts Need to correctly document insulin administration times Duplicate dose Document How to Avoid Inappropriate Insulin Use Syringe (Insulin Syringe) Know what syringe you are using 1 ml : 100 units 1/2 ml : 50 units 3/10 ml : 30 units Label your syringe Mistakes can and will happen! 6

7 Insulin How to Avoid Inappropriate Insulin Use Sound alike and look alike Humalog and Humalog Mix HumaLOG and HumuLIN Glulisine and Glargine Be aware of which insulin is considered prandial and basal Patient Specific Causes of Hypoglycemia Too much insulin Change in dietary status Changing to NPO TPN or enteral feeds discontinued Decreased PO intake Change in steroid use Steroids discontinued or tapered down Acute renal or hepatic failure Mealtime insulin given too early prior to meal 30 minutes before meal 7

8 U units/ml Others: 100 units /ml U 500 uses a different syringe Tuberculin syringe Extremely important to obtain accurate medication history Insulin Errors at Palomar Health Medication Error Type Incidents Percentage of Errors A % B % C % D % E % F 2 4.9% Total % 8

9 Insulin Errors at Palomar Health Medication Error Type Incidents Percentage of Errors A % B % C % D % E % F 2 4.9% Total % Insulin Errors at Palomar Health Medication Error Type Incidents Percentage of Errors Administration % Prescription Order % Communication Prescribing % Monitoring % Dispensing 3 9.7% Distribution 2 6.5% Compounding 2 6.5% Total % 9

10 Insulin Errors at Palomar Health Medication Error Type Incidents Percentage of Errors Administration % Prescription Order % Communication Prescribing % Monitoring % Dispensing 3 9.7% Distribution 2 6.5% Compounding 2 6.5% Total % Take Home Point Insulin errors happen throughout every single step of the continuum of care Prescribing Order Communication Storage Compounding Dispensing Administering Monitoring We are all responsible for safe insulin use! 10

11 References American Diabetes Association Standards of Medical Care in Diabetes Diabetes Care 2015; 38 (Suppl. 1): S1 S2. Cobaugh DJ, Maynard G, et al. Enhancing insulin use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel. Am J Health Syst Pharm. 2013; 70: Cousins D, Rosario C, Scarpello J. Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency. Clin Med. 2011; 11: Insulin Lispro. In: Clinical Pharmacology [database from the internet]. Tampa (FL): Gold Standard; Palomar Health Diabetes Medication Clinical Practice Guidelines. Pasala S, Dendy JA, Chockalingam V, et al. An inpatient hypoglycemic committee: development, successful implementation, and impact on patient safety. The Ochsner Journal. 13; ,

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