Changes to medication-use processes after overdose of U-500 regular insulin

Area of Science:

• Pharmacology
• Patient Safety
• Health Systems Pharmacy

Background:

• Medication errors pose significant risks in healthcare settings.
• High-concentration insulins, such as U-500 regular insulin, require specialized handling due to their potency.
• Existing safety measures may be insufficient for managing potent medications like U-500 regular insulin.

Observation:

• A medication error involving U-500 regular insulin prompted a review of current medication-use processes.
• A multidisciplinary team identified inadequate safety practices for U-500 regular insulin.
• The team noted the need for specific interventions to mitigate risks associated with U-500 regular insulin.

Findings:

• New safety processes were developed and implemented for U-500 regular insulin.
• Dispensing was restricted to the pharmacy, with separation from other insulins.
• Ordering was limited to the endocrinology service, utilizing a specialized order set.
• Intravenous administration was removed, restricting use to subcutaneous routes.
• Preparation involved tuberculin syringes with double pharmacist checks and "high alert" labeling.
• A two-nurse bedside check was instituted for final verification.

Implications:

• The implemented safety modifications have effectively prevented further medication errors involving U-500 regular insulin.
• These changes demonstrate a successful approach to improving medication safety for high-alert medications.
• The revised medication-use system serves as a model for managing potent drug products in healthcare institutions.