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
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
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): 211-218
Background Rationale for treatment with Humulin R U-500 - 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.
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
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
Prevalence of Administration Errors Methods: Retrospective audit of PRIME events involving Humulin R U-500 insulin between 2009-2014 Results: 8 patients prescribed Humulin R U-500 5 errors 2 under-dosing, 1 over-dosing, 2 potential under-dosing (near miss)
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
Potential Factors for Error
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
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
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
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
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
Standardised Prescribing
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
Labelling Vial
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
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)
Staff Education Program: Instructional Video
Ward Poster
Patient Alerts
Patient Education Brochure
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
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