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Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy
  1. Michael J Dooley1,2,
  2. Meredith Wiseman1,2,
  3. Amy McRae1,
  4. Danielle Murray3,
  5. Melita Van De Vreede4,
  6. Duncan Topliss5,6,
  7. Susan G Poole1,2,
  8. Sue Wyatt7,
  9. Harvey Newnham6,8
  1. 1Pharmacy Department, Alfred Health, Prahran, Victoria, Australia
  2. 2Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Australia
  3. 3Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
  4. 4Pharmacy Department, Eastern Health, Melbourne, Australia
  5. 5Department of Endocrinology and Diabetes, Alfred Health, Prahran, Victoria, Australia
  6. 6Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
  7. 7Diabetes Education, The Department of Endocrinology and Diabetes, Alfred Health, Prahran, Victoria, Australia
  8. 8General Medicine, Alfred Health, Prahran, Victoria, Australia
  1. Correspondence to Professor Michael J Dooley, Pharmacy Department, Alfred Health, Commercial Road, Prahran, Victoria, Australia; m.dooley{at}alfred.org.au

Abstract

Background Insulin is a high-risk medicine which may cause significant patient harm or death when given incorrectly. A 10-fold error in administered insulin dose commonly occurs when the abbreviation ‘u’ is used for ‘units’ and subsequently misinterpreted as a ‘zero.’

Method A multidisciplinary working party was convened and mapped insulin prescribing, dispensing and administration. All inpatient orders above 25 units for short-acting insulin and 50 units for other insulin require validation by an additional source. Educational strategies to support adherence to the guideline and product-labelling alerts were developed.

Results Implementation occurred in August 2008 across the three hospital sites. In 90 weeks after implementation, there were 150 patients identified in which 200 high doses of insulin were prescribed (>25 units for short-acting insulin and 50 units for other insulin). There were eight instances where high doses of insulin were prescribed in error but were detected and rectified through the new validation process. There were 12 dosing errors that occurred, including two 10-fold dosing errors. In contrast, seven major errors resulting in excessive insulin administration were identified over a 2-year period prior to the introduction of the insulin high-dose validation system.

Conclusion A structured validation process was successful in reducing incorrect prescription and administration of high-dose insulin and has reduced the risk of associated fatalities or significant patient harm. Consideration should be given to adopting this process in any setting where insulin is prescribed and administered.

  • Insulin
  • error
  • safety
  • hospital
  • human error
  • medication error
  • medication safety
  • risk management

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Footnotes

  • Competing interests None.

  • Ethics approval Ethics approval was provided by The Alfred Research and Ethics Unit.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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