Patient Safety Authority Analysis Reveals High Number of Dosing Errors With Insulin Products

Tuesday, March 2, 2010 Diabetes News
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Analysis of data related to insulin medication errors and a local hospital's success in reducing hospital readmission costs are highlighted in quarterly journal

HARRISBURG, Pa., March 1 /PRNewswire-USNewswire/ -- Pennsylvania healthcare facilities submitted over 2,600 event reports that involved the use of insulin products to the Patient Safety Authority where more than 52 percent led to situations in which a patient may have or actually received the wrong dose or no dose of insulin. The data raises awareness of a broader issue that is highlighted in the 2010 March Pennsylvania Patient Safety Advisory.

Of the 2,685 event reports submitted to the Pennsylvania Patient Safety Authority between January 2008 and June 2009, 78 percent (2,113) reached the patient and in 1.8 percent of the reports (49) the patient was harmed. The most common types of medication error associated with insulin were drug omission (24.7%) followed by wrong-drug errors (13.9%).

Matthew Grissinger, RPh, FISMP, FASCP, analyst for the Pennsylvania Patient Safety Authority and director of Error Reporting Programs at the Institute for Safe Medication Practices (ISMP), said the data submitted by Pennsylvania's healthcare facilities reflects nationwide studies. The issue not only raises concerns for the estimated 23.6 million Americans (nearly 8% of the U.S. population) who are diabetic, but also non-diabetic patients who may require insulin while in the hospital.

"The bottom line is that the better a patient's blood glucose levels are controlled, the better quality of life that patient will lead," Grissinger said. "It's in the best interest of the patient for healthcare facilities to implement strategies that will help reduce the risk of medication errors associated with insulin."

Grissinger added that in 2004 the Authority established that 25 percent of all medication errors reported involved high-alert medications of which 16.3 percent involved insulin products. Subsequently, a national study done by U.S. Pharmacopeia in 2008 shows that insulin is the leading product involved in harmful medication errors.

"Unfortunately, the issue with medication errors and insulin drugs is not new, but the Authority does offer healthcare facilities a new patient safety tool and strategies for facilities to use to help reduce the risk," Grissinger added.

The patient safety tool allows healthcare institutions to document facility-specific process and outcome measures involving the use of insulin for better tracking of insulin-related drug events.

"In order to more successfully monitor medication safety with the use of insulin, facilities should consider other measures in addition to error reporting," Grissinger said. "For example, the process and outcome measures we have incorporated into the tool can be utilized to determine the existence and extent of a problem as well as evaluate the effectiveness of efforts to improve the problem."

Along with the patient safety tool, the Authority also provides patients and families with consumer tips to help them protect themselves from medication errors related to insulin products.

For more information on the data and studies related to medication errors and insulin products go to the Advisory article, "Medication Errors with Dosing of Insulin: Problems across the Continuum," at

Also in the 2010 March Advisory, hospital readmissions become an issue for patient safety and financial savings. Hospitalizations account for nearly one-third of the $2 trillion spent on healthcare in the United States annually.

Data from the Pennsylvania Healthcare Cost Containment Council (PHC4) shows that in 2008 there were 57,852 readmissions in healthcare facilities amounting to approximately $2.5 billion in charges. Thirty-eight percent of these readmissions were related to complications or infections.

From June 2004 through August 2009, 1,791 reports described as "unplanned returns to the emergency department within 48 hours" and which also required hospital admission were submitted to the Authority. Eight percent of these reports were Serious Events (causing harm to the patient). A total of 3,500 hospital readmissions were reported within that time period.

"For most people who have to go back into the hospital it is necessary and appropriate. However, experts estimate that as many as twenty percent of hospitalizations are those where the patient was just in the hospital less than thirty days before," Mike Doering, executive director of the Pennsylvania Patient Safety Authority said. "These hospitalizations are costly, potentially harmful and often preventable."

Doering said Geisinger Health System in Danville, Pennsylvania, implemented a medical home concept that resulted in a decrease in the system's readmission rate by 44 percent and a decline in overall treatment costs.

"Geisinger has adopted a system that focuses on patient care by a team of healthcare practitioners working together across the care continuum, as opposed to departmental care provided by different doctors or nurses from different care areas at different times," Doering said. "The approach gives doctors financial incentives for providing patients with more direct care even after they've left the hospital and for doing additional research related to a patient's care."

Doering added that Geisinger also changed the way it charges for services. For example, for a number of surgeries, costs are bundled into a single flat fee. If the patient experiences complications or needs additional treatment within 90 days, the system covers the costs.

"Geisinger has done its homework," Doering said. "It recognized a problem, then developed and implemented a strategy that worked to reduce costs. I encourage other healthcare facilities to take a look at what Geisinger has done and review the strategies provided in the Advisory to reduce hospital readmission costs."

For more information about the hospital readmissions data and strategies to reduce them, go to the 2010 March Advisory article "Leveraging Healthcare Policy Changes to Decrease Hospital 30-day Readmission Rates" at

The Authority's quarterly March Advisory contains other articles developed from data submitted about real events that have occurred in Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions. Highlights include:

X-Rays Ordered in Emergency Rooms May Not Be Reviewed in a Timely Manner: In 2008, facilities submitted 195 reports to the Authority citing discrepancies between an emergency room (ED) physician's opinion of an x-ray and the final opinion from a radiologist needed to confirm the results of the x-ray. A process must be in place for radiologists to communicate such discrepancies in a timely manner to ED providers to ensure patients will receive appropriate follow-up care. This article examines risk reduction strategies that include standardizing communication systems between ED physicians and radiologists.

Preventing Corneal Burns During Cataract Surgery: Twenty reports of corneal burns during cataract surgery have been submitted to the Authority from December 2004 through July 2009. Surgical staff must be aware of any condition that could reduce delivery of saline, which cools the probe used to extract the lens. This article identifies several conditions known to reduce saline delivery and provides guidance for avoiding these conditions.

Wrong-Site Surgery Quarterly Update: This article provides an update on events of wrong-site surgery in Pennsylvania. Steady progress continues in preventing wrong-site surgeries with some curves along the way. Wrong-site local and regional anesthesia blocks are a major contributor of wrong-site operating room procedures. Seven new reports have been submitted, all of which had little information to confirm the side. The Authority has begun an on-site consultation program for Pennsylvania facilities that wish to analyze their vulnerability for wrong-site surgery. Requests can be made through the Authority office or the regional Patient Safety Liaison.

For a copy of the 2010 March Pennsylvania Patient Safety Advisory or more information on the Pennsylvania Patient Safety Authority, visit the Authority's Web site at

SOURCE Patient Safety Authority

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