Reducing Insulin Administration Errors: The Independent Double Check Warren Prokopiw, BSc, BSP, M Eng Cynthia Turner, BPharm Michele Babich BSc(Pharm), MHSA

Background Accreditation Canada verification processes for high risk activities1 Institute for Safe Medication Practices independent double check for high alert medications2 BC Patient Safety and Learning System Voluntary reporting system for trend analysis Known to under-report actual rates3 Narcotics, antithrombotics, ionotropes, insulin, potassium, magnesium, nitroprusside, methotrexate, oxytocin

Background Independent Double Checks (IDCs)4 Second practitioner verifies a procedure No communication of expected result from first practitioner Removes bias Maximize catching errors

Objectives Primary Secondary To determine which medication has the highest administration events within VIHA To quantify the change in events occurring after implementation of independent double checks Secondary To investigate if simplifying event documentation increases the rate of voluntary reporting

Methods Review of historical PSLS reports

Methods D Single center, prospective study with retrospective controls identified through dispensing records as having received insulin in acute or extended care at SPH during study periods I start IDCs with new diabetic record and education by Clinical Nurse Educator simplify event reporting with near miss codes data collected 7 Nov 2011 to 31 Mar 2012 C standard insulin administration and PSLS event reporting data collected 1 Sep 2010 to 31 Jul 2011 O administration events of incorrect product, dose or time event rate per dose administered, events prevented by double check

Methods

Results Event/Dose contingency table and rates p = 0.0446 Missed doses not included in the study n=6

Results Trial Pre and Post IDC Events

Conclusions Institution of independent double checks significantly reduced the number of insulin events per dose administered compared to pre-implementation A good catch demonstrated IDCs work Simplification of event documentation did not increase the rate of voluntary reporting In the future, we plan to expand independent double checks for insulin administration throughout VIHA

Error Reporting

References Accreditation Canada ROP Handbook 2011;28 ISMP Canada Safety Bulletin 2005;5(1) Classen D Qual Saf Health Care 2005;14 221–226. VIHA Medication P&P D.22

Thank you!