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

2. 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

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

4. 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

5. Methods
Review of historical PSLS reports

6. 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

7. Methods

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

9. Results
Trial Pre and Post IDC Events

10. 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

11. Error Reporting

12. 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

13. Thank you!