Safe use of Insulin in hospital settings relies on best labelling practices. When a team from Richmond Hospital identified a problem with inconsistent labelling of Insulin, they collaborated with their Pharmacy and Medication Safety Committee to implement a new labelling protocol. We’re sharing their story so others across the province can benefit from their experience and practical approach to solving a medication safety issue.
Insulin is a “high alert” medication. Errors in dosing or administration, or the use of contaminated or outdated Insulin, can result in serious patient safety events with severe patient consequences. Clear and consistent labelling on Insulin bottles is especially important to reduce the possibility of misinterpretation and errors by healthcare staff. Cheryl Chan, Educator, 3 Medicine Sub-Acute/Transitional Care Unit (TCU), says “The issue with Insulin labelling came up during our daily staff safety huddles. That’s a venue where we discuss medication safety and staff were very concerned about Insulin.”
The recurrence of this issue in BC PSLS indicated that two Insulin labels was a risk to patient safety.
Nursing staff and students were concerned about two different Insulin labels that included dates. One referred to “Date opened” and the other had a “Do not use after” date. Use of both labels created a high risk for mistakes to occur. One of the main concerns was the potential risk that patients could be given outdated Insulin, which can be less potent than expected.
“It was causing a lot of confusion among the staff and I noticed several reports about this issue in PSLS. Many of our patients are insulin-dependent so it was a recipe for disaster; the margin for error was too big.”
Cheryl went to Mark Wu, Pharmacist and Chair of the Medication Safety Committee, and shared her concerns. “I explained that two similar labels with two different meanings was a patient safety issue. We spent a lot of time discussing this and investigating what other programs do. It took some time, but we agreed that one label is best – the DO NOT USE AFTER label.”
Medication Safety Committee Newsletter Richmond Hospital (February 2016)
The new labelling standard for Insulin ward stock and patient-specific vials was put in place on February 26. This label change eliminates the need for healthcare staff to try and interpret the meaning of two different labels, thereby reducing the risk.
“This is exactly what PSLS is for,” Cheryl says. “The system allows me to highlight and discuss patient safety issues with the staff. In addition, identifying the recurrence of the same medication errors identifies the need for a system process review. The members of our Medication Safety Committee were exemplary in their support for helping us to rectify this medication safety issue for our patients.”
Learn more about Knowledge Translation of Insulin Use Interventions / Safeguards (ISMP Canada)
- The “DO NOT USE AFTER” label is the only label used for Insulin (as of February 26)
- Shelf-life of an open Insulin bottle exposed to air is 28 days
- Staff double-check dates on Insulin bottle labels before administration
Additional resources:
- Island Health introduces “Insulin Safety Initiative” for patients and staff
- Life-threatening near miss: Sharing lessons learned with BC care providers
For more information about this medication safety initiative, please contact Cheryl at Cheryl.Chan@vch.ca