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Purpose Three insulin administration errors that occurred after a hospital’s transition from insulin pens to vials are described, and process improvement initiatives implemented to prevent future errors are reviewed.
Summary In response to numerous reports and warnings related to the risk of insulin pen sharing, a 450-bed community hospital made a transition from insulin pens to insulin vials. Shortly after this transition, three major medication errors involving insulin occurred. Root-cause analysis of the errors identified numerous contributing factors, such as incomplete nursing staff education, issues with the electronic medical record, and lack of adherence to medication administration policies and procedures. In response to these errors, process improvement initiatives were implemented to prevent future errors from occurring. These process improvement initiatives consisted of (1) providing education to nurses, (2) revising the appearance of the electronic medical record, (3) emphasizing the importance of using insulin syringes exclusively for insulin administration, (4) performing safety rounds to confirm proper safety checks, and (5) implementing daily improvement huddles hospitalwide. Newly implemented initiatives to help ensure safe insulin use included involving frontline nursing staff in medication safety committee meetings and requiring that all insulin glargine doses be prepared in designated insulin syringes in the pharmacy for dispensing to patient care units.
Conclusion After three major insulin administration errors, a review of processes and contributing factors was conducted. With additional education of nurses, improved staff communication, and implementation of other safety initiatives, no insulin administration errors were reported in the following year.
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