Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy

Dooley, Michael; McRae, Amy; Murray, Danielle; Vreede, Melita Van de; Topliss, Duncan J.; Poole, Susan; Wyatt, Sue; Newnham, Harvey

doi:10.1136/bmjqs.2010.049668

Cited by 12 publications

(19 citation statements)

References 23 publications

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“…All were uncontrolled before-after studies. Four studies were multisite [19,28,30,32], seven involved teaching or tertiary hospitals [26][27][28][29][30][31]33] and three studies involved district general hospitals [18,19,25].…”

Section: Interventions To Improve Insulin Prescribing Accuracy and Comentioning

confidence: 99%

“…There was a lack of consistency with respect to the methodology and outcome measures used in the studies. Seven studies measured the reduction in insulin prescribing errors [18,19,[25][26][27][28]32], three measured the accuracy, clarity and completeness of prescriptions [29,31,33], and one study measured opportunity for error as a result of unclear prescribing [30]. The types of intervention varied, as well as the implementation strategies, and measures of improvement between studies (see Table S4).…”

Section: Interventions To Improve Insulin Prescribing Accuracy and Comentioning

confidence: 99%

“…The types of intervention varied, as well as the implementation strategies, and measures of improvement between studies (see Table S4). Although three studies [19] x Courtenay 2007 [17] x x Donihi 2006 [26] x x Dooley 2011 [28] x Donsa 2016 [27] x x Doyle 2014 [54] x x x x Ena 2009 [41] x x Gomez-Huelgas 2014 [55] x x Guerra 2010 [43] x x x Hamilton 2013 [18] x Harbin 2015 [36] x x Helmle 2017 [37] x x x x x x x Horton 2015 [44] x Kowiatek 2001 [29] x x x x Lehnbom 2009 [35] x x Mamillapalli 2012 [38] x Maynard 2009 [45] x x x McIver 2009 [30] x x x Mulla 2015 [39] x x x Newsom 2018 [15] x x x x Noschese 2008m [46] x x Rushmer 2008 [31] x x x Schnipper 2009 [47] x x x Schnipper 2010 [48] x Taylor 2012 [32] x Thompson 2009 [49] x x x Trujillo 2008 [50] x x Tully 2018 [33] x x x Vaidya 2012 [56] x Valgardson 2015 [52] x x Wesorick 2010 [34] x x Wexler 2010 [52] x Wong 2016 [40] x x Yeung 2018 [53] x x ª 2019 Diabetes UK used the UK's National Inpatient Diabetes Audit (NaDIA) methodology and data collection tool, the follow-up period, interventions, implementation and the data reported were varied, hence it was difficult to pool data or make meaningful comparisons [18,19,32]. The introduction of simple, small focused interventions led to an improvement in the completeness and accuracy of insulin prescribing, particularly when they involved 'hard stops' (such as pre-printi...…”

Section: Interventions To Improve Insulin Prescribing Accuracy and Comentioning

confidence: 99%

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Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review

2019

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Aim To conduct a systematic review of literature to identify interventions that are effective in improving insulin prescribing for people with diabetes in the hospital setting. Methods Computerized bibliographic databases were searched for studies published in English that described the effectiveness of interventions to improve insulin prescribing within the hospital setting. Studies were eligible for inclusion if they reported data that compared insulin prescribing practice after an intervention or compared with a control group. Studies were not excluded on the basis of publication date, geographical location or risk of bias assessment. Results We identified 35 studies for inclusion in the review, including two cluster randomized controlled trials, two cohort studies, and 31 uncontrolled before–after studies. Studies reported a variety of interventions that aimed to increase insulin prescribing accuracy or completeness or decrease the use of discouraged subcutaneous sliding scale insulin regimens. Differences in definition of insulin prescribing error, terminology and common practice based on geographical location was evident, and quality issues with respect to study design and reporting somewhat limited the interpretation of conclusions. Conclusions Implementing strategies that are sensitive to local context and designed to increase adherence to insulin prescribing guidelines are associated with a reduction in prescribing errors. Future implementation should build on effective approaches including multifaceted interventions involving multiple stakeholders at various institutional levels. Future studies in insulin prescribing errors would benefit from the use of standardized approaches, terminology and outcome measures to enable greater comparison.

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Section: Interventions To Improve Insulin Prescribing Accuracy and Comentioning

confidence: 99%

Section: Interventions To Improve Insulin Prescribing Accuracy and Comentioning

confidence: 99%

Section: Interventions To Improve Insulin Prescribing Accuracy and Comentioning

confidence: 99%

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Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review

2019

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“…As an example, illegible writing of the letter ‘u’ in place of units can lead to a 10‐fold increase in the dose of insulin being given, with lethal consequences 9. Elsewhere, the use of a structured validation system to review highdose insulin prescribing and administration, supported by education and product alerts, was successful in reducing the risk and incidents of these potentially fatal medication errors 10…”

Section: Discussionmentioning

confidence: 99%

Reducing insulin prescription errors in hospital: more stick than carrot?

et al. 2013

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In order to improve the flow uniformity in a plate‐fin heat exchanger (PFHE), a modified header structure with a plain baffle inside is proposed. Flow distribution and pressure drop in the header were studied by numerical methods. The results show that the modified header is highly efficient in improving the flow uniformity with negligible pressure drop increase. A performance effectiveness factor was introduced to predict the effects of the modified structure on the performance of the PFHE. Influences of baffle structure parameters on modified structure performances were further discussed. The modified header structure can effectively improve the performance of a PFHE.

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“…Moreover, current evidence on the effectiveness of CPOE in preventing prescribing errors is inconclusive, and CPOE may introduce new types of prescribing errors . Other published interventions include prescribers’ education, prescribers’ assessment and validation, feedback to prescribers about errors, avoiding error‐prone abbreviations and medication chart design . Interestingly, the effects of environmental factors on prescribing errors have not been studied to the same extent, even though these factors have been highlighted by junior medical officers (JMOs) as the main causes of prescribing errors …”

Section: Introductionmentioning

confidence: 99%

Effectiveness of ‘do not disturb’ strategies in reducing errors during discharge prescription writing

Zamani

Hall

Cunningham

et al. 2019

Pharmacy Practice and Res

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Background Prescribing errors not only impose safety risks, but also delay hospital discharges and adversely affect patient satisfaction. The effect of reducing environmental interruptions on prescribing errors has not been published previously. Aim The aim of this study was to determine the combined effect of two ‘do not disturb’ (DND) strategies in decreasing the average number of prescribing errors by reducing distractions during discharge prescription writing. A secondary aim was to assess the effect of the interventions on prescription correction time. Methods In all, 392 discharge prescriptions from two general medical wards of a teaching hospital were audited over a 10‐week period in a prospective interventional before‐and‐after audit. Clinical pharmacists collected data on the number and type of errors, and time taken to correct errors. DND vests and workstations were made available during the intervention phase. Junior medical officers (JMO) provided daily feedback to the nurse unit managers (NUM) on the number and source of distractions, as well as the use of DND vests and workstations after the intervention. Results The percentage of error‐free discharge prescriptions increased from 29.7% before to 51.5% after the intervention (p < 0.0001). The mean number of errors per prescription decreased from 1.7 to 1.1 (p < 0.01) in both wards combined. The median time taken to correct erroneous prescriptions did not change significantly. Feedback provided by JMOs showed a marked reduction in interruptions, with 73% stating they were not interrupted at all or just once during prescribing after the intervention, compared with 17% before the intervention. Conclusion DND strategies decreased the rate of erroneous prescriptions.

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Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy

Cited by 12 publications

References 23 publications

Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review

Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review

Reducing insulin prescription errors in hospital: more stick than carrot?

Effectiveness of ‘do not disturb’ strategies in reducing errors during discharge prescription writing

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