Decreasing risks of medication errors in patients prescribed Humulin R U-500

Transcription

1 Decreasing risks of medication errors in patients prescribed Humulin R U-500 Denise Bennetts BN, BEd; Megan Masko BN Department of Diabetes and Endocrinology Princess Alexandra Hospital, Brisbane, Qld

2 Issue: Prime Report 62yo male with history of T2DM Admitted to one of PA Hospital wards Prescribed 28 marks (140 units) of Humulin R U-500 insulin Actually administered 140 marks which was 1.5 syringes of insulin (= 700 units of insulin!) 20 mins later MET call for loss of consciousness

3 Background Humulin R U-500 Is a high potency insulin (500 units/ml) which is 5 times the concentration of conventional insulin (100 units/ml) Available in Australia via the special access scheme Used in the management of diabetes associated with severe insulin resistance requiring large doses of insulin Increasing usage due to parallel epidemics of type 2 diabetes and obesity * * Cochran E, Gorden P, Insulin. 2008;3 (4):

4 Background Rationale for treatment with Humulin R U reduction in dose volumes - fewer total number of daily injections - patient satisfaction - potential improvement in glycaemic control * * Cochran EK et al.. The Diabetes Educator 2014; 40:153.

5 Aims 1. Identify the prevalence of administration errors involving Humulin R U-500 insulin 2. Identify the factors leading to administration errors involving Humulin R U-500 insulin 3. Develop and institute an education program to prevent further prescribing and administration errors involving Humulin R U-500 insulin

6 Aims 1. Identify the prevalence of administration errors involving Humulin R U-500 insulin 2. Identify the factors leading to administration errors involving Humulin R U-500 insulin 3. Develop and institute an education program to prevent further prescribing and administration errors involving Humulin R U-500 insulin

7 Prevalence of Administration Errors Methods: Retrospective audit of PRIME events involving Humulin R U-500 insulin between Results: 8 patients prescribed Humulin R U errors 2 under-dosing, 1 over-dosing, 2 potential under-dosing (near miss)

8 Aims 1. Identify the prevalence of administration errors involving Humulin R U-500 insulin 2. Identify the factors leading to administration errors involving Humulin R U-500 insulin 3. Develop and institute an education program to prevent further prescribing and administration errors involving Humulin R U-500 insulin

9 Potential Factors for Error

10 Potential Factors for Error No dedicated pen or syringe available Must be administered using U-50 or U-100 insulin syringe graduating in 1 unit increments Small number of patients using Humulin R U-500 meaning staff are not familiar with it Terminology for prescribing ambiguous Marks vs. Units

11 Aims 1. Identify the prevalence of administration errors involving Humulin R U-500 insulin 2. Identify the factors leading to administration errors involving Humulin R U-500 insulin 3. Develop and institute an education program to prevent further prescribing and administration errors involving Humulin R U-500 insulin

12 Prevention Program Recommendations: 1. Implement strict institutional policies about how to prescribe and administer 2. Ensure appropriate drug labelling 3. Develop and implement a patient and staff education program led by the DNE

13 Prevention Program Recommendations: 1. Implement strict institutional policies about how to prescribe and administer 2. Ensure appropriate drug labelling 3. Develop and implement a patient and staff education program led by the DNE

14 Prevention Measures Changes to hospital policies: Medication alerts in ED and electronic information systems and e-health record To contact Endocrine Registrar at the time of admission To assess patient safety to self-medicate To contact DNE for staff education on ward Store and lock Humulin R U-500 in patient bedside medication drawer

15 Standardised Prescribing

16 Prevention Program Recommendations: 1. Implement strict institutional policies about how to prescribe and administer 2. Ensure appropriate drug labelling 3. Develop and implement a patient and staff education program led by the DNE

17 Labelling Vial

18 Recommendations: Prevention Program 1. Implement strict institutional policies about how to prescribe and administer 2. Ensure appropriate drug labelling 3. Develop and implement a patient and staff education program led by the DNE

19 Staff Education Program Develop and implement an intensive nursing education program Instructional video accessible via hospital intranet Inservice nursing staff Assess the program by: - Pre-survey - Inservice - Post-survey (76% knowledge improvement)

20 Staff Education Program: Instructional Video

21 Ward Poster

22 Patient Alerts

23 Patient Education Brochure

24

25 Summary Humulin R U-500 is a management option for patients with diabetes and significant insulin resistance Use of Humulin R U-500 carries a significant risk for potential fatal prescribing and administration errors Clinicians and patients need to be aware of safety issues associated with Humulin R U-500 Safety procedures, staff education and resources need to be developed to avoid risk of medication errors and to enhance patient safety

26 Acknowledgements Diabetes Educators Assoc. Professor Anthony Russell, Director of Diabetes and Endocrine Dept. Dr. Viral Chikani, Consultant Endocrinologist Dr. Kerri Holzhauser, Director Nursing Research Karen Boch, Medication Safety Advisor Lee Allam, Assistant Director of Pharmacy