The Institute for Safe Medication Practices Canada considers insulin as one of the Top 5 “high alert” medications due to its narrow therapeutic index and its frequency of use. When used in error, insulin has an increased risk of causing significant patient harm – “too high” a dose may cause hypoglycemia, which can result in falls leading to fractures, or “too low” a dose may cause hyperglycemia and progressive end organ disease (e.g. kidney, heart) over the long term. Either way, these situations can be extremely harmful and may lead to longer hospital stays or future hospitalizations.
To learn more about why insulin-related events occur and establish best practices to prevent them, Island Health recently undertook an extensive evaluation of their BC PSLS data, focusing specifically on patient safety events involving insulin.
“We needed to understand why these potentially harmful events were occurring at Island Health facilities,” says Cynthia Turner, Medication Safety Pharmacist. “So, with the help of Carly Webb, UBC Pharmacy Student, we conducted a comprehensive study of all insulin-related events reported in BC PSLS over a one-year period (August 1, 2011 – July 31, 2012). This allowed us to pinpoint at what point of care insulin events were happening most, which ultimately laid the groundwork for our prevention and education strategies.”
Through their research, Cynthia and colleagues learned that “Administration” was the most common stage for an insulin error to occur, accounting for 80% of all insulin events reported at Island Health.
- Selecting the incorrect type of insulin
- Drawing up the incorrect dose
- Misreading the order
- Neglecting to give a dose
- Giving the supper dose at bedtime
“The data we collected from BC PSLS provided valuable insight into the nature of insulin events reported by healthcare staff at Island Health,” says Cynthia. “With that data available to us we could identify the causes, trend these events over time, and focus our patient safety projects accordingly.” Dr Donna Buna, Clinical Coordinator VGH Pharmacy, worked together with Cynthia obtaining input from the relevant clinicians prior to implementation and on formulating a plan from a systems, educational, front-line practice and medication safety standpoint.
By September 2012, the team launched an “Insulin Safety Initiative” jointly sponsored by the Pharmacy Quality Council and Chronic Disease Management. The “Insulin Safety Quality Assurance Project” involved multidisciplinary team work between pharmacy staff, physicians, and nurses. Cynthia stated that they had the support of Dr. David Miller, Head Endocrinology VIHA, and that they collaborated with the Diabetes Nurse Educators at the Royal Jubilee, Victoria General and Nanaimo Regional General Hospitals.
As a result, the following insulin safety strategies are now in place at Island Health:
- Insulin has been added to VIHA’s list of “high alert” medications which includes incorporating an independent double check prior to administration, standardization of ward stock and segregated storage
- An educational video was created to communicate the control strategies put in place and the reasons for these key changes; this video can be viewed by clicking here
- A Diabetes Resource Centre was created on the VIHA Intranet as a repository of educational materials for both patients and staff
The team plans to repeat their analysis of reported insulin events later this year.
This is a great example of how BC PSLS is helping to improve patient safety…nice work Cynthia and colleagues!
Cynthia Turner is Medication Safety Pharmacist at Island Health (VIHA). For more information about this initiative, please email Cynthia.Turner@viha.ca