1. Christopher Patty, DNP, RN, CPPS Kaweah Delta Medical Center Visalia, California

2. “The hospital is great at adding things for nurses to do, but they never take anything away”

3. Addiction (def.) “Compulsive engagement in rewarding behavior despite adverse consequences”

4. The DV process induces many distractions, interruptions, procedural failures and clinical errors Nurses hate it Patients aren’t crazy about it either

6. Distraction (antonym: concentration) is something I do to myself “…I need to find another nurse to DV this insulin” Interruption is something I do to someone else…”Hey, will you check this insulin with me?”

7. DV can reduce errors by 30% if done correctly Two clinicians separately check; Alone and apart from one another; Then compare results; For prescribing, dispensing and verifying DV is inconsistently practiced (Brannan, 2010) Errors occur despite DV (Armitage, 2008) DV becomes superficial routine task (Smetzer, 2003)

8. Staff aren’t really doing independent double verification Staff treat DV as a mindless robotic rote task Deviance from ideal practice has been normalized Staff cannot articulate prevented errors Every insulin error has been in the DV era 40% of SQ insulin doses are 1 unit

9. All our orders were in paper charts We did the transcribing/decoding Before pharmacist’s prospective review of orders Before automated dispensing cabinets Before barcode medication administration Before POC blood glucose testing Before 1/3 rd of our patients were diabetic

10. “Our safety consulting staff recommends independent double checks for IV but not SQ insulin, because these almost certainly will not be properly conducted due to volume of doses needing a check” “We are fine if any individual nurse giving subcutaneous insulin wants to ask for a check by a second individual, but we don't believe it should be a requirement in most situations.” – Michael Cohen, April 2013 “Independent double-checks must be strategically placed for just a few high-alert medications”

11. It’s required by JCAHO, Title 22, CMS, etc That’s the way I was trained Insulin is a “high alert” medication. Patients die from insulin overdoses! Two heads are better than one Better to do something than do nothing. Everyone else is doing it We’ve always done it that way It’s policy We don’t want to stop for the wrong reasons

12. Keeps nurses and patients together Allow nurses to practice to the full extent of their licensure (IOM, 2011) Avoid waste in all its forms including wasted thought (IOM, 2001) Reduces the number of distractions and interruptions during medication administration

16. “When you need me to double-verify your insulin, I’m in the middle of giving mine”

17. Patient Safety No change in glycemia profiles pre- and post- intervention No change in self-reported ADE pattern Nurse Satisfaction Reduced interruptions, especially during medication passes More time with patients RN confidence in process Cost Avoidance Waste reduction

18. Explained rationale for change Reducing distractions/interruptions Made DV voluntary for SQ insulin A few continue DV Instructed RN in procedure for BCMA override, documentation Observed RN give SQ insulin dose Follow-up visits over a month

19. 1.Reduce the number of steps in the process. 2.Increase the reliability of individual process steps. Process (def.) A series of steps leading to a result Process AProcess BProcess CProcess D Step 199% Step 2---99% Step 3--- 99% Step 4--- 99% Overall Reliability99%98%97%96%

20. Forcing Functions Constraints Automation Computerization Protocols & Order Sets Double Checks Rules and Policies Education Fixing People Fixing Systems

21. Total Hours in DV Activity (1.5 - 3” per DV event) 112,516 events 2812 - 5625 Estimated Interruptions (4:1 ratio med pass : interruption) 28,129 Estimated Clinical Errors Induced by DV (+12.7% risk per)3772 Annual Cost of DV-Induced Error (1% harmful errors, $8750 ea) $330,500 Interruptions during medication pass, self-reported (pre)95% Interruptions during medication pass, self-reported (post)14% Agree/strongly agree discontinuing DV ↑ patient safety risk 5%