Does an Insulin Double-Checking Procedure Improve Patient Safety?

Area of Science:

• Pharmacology
• Patient Safety
• Healthcare Quality Improvement

Background:

• Insulin administration errors constitute 3.5% of medication errors.
• Leading healthcare organizations recommend a two-nurse double-checking process for insulin preparation.
• This underscores the critical need for interventions to improve insulin administration safety.

Purpose of the Study:

• To evaluate the efficacy of a subcutaneous insulin double-checking preparation intervention.
• To determine its impact on reducing insulin administration errors.
• To identify specific error types affected by the intervention.

Main Methods:

• A randomized, controlled, nonblinded, intent-to-treat study design was employed.
• Data were collected over four weeks involving 266 patients and 5238 insulin administration opportunities.
• Comparison was made between a double-checking group and a usual care group.

Main Results:

• The double-checking group demonstrated a higher incidence of error-free insulin administrations compared to usual care.
• Wrong-time errors were the most frequent type but were less prevalent in the double-checking group.
• Omission errors were infrequent and also reduced in the double-checking group.

Conclusions:

• The subcutaneous insulin double-checking preparation procedure effectively reduced overall insulin administration errors.
• However, the intervention did not resolve the predominant timing errors.
• Further research is needed to address persistent timing-related insulin administration errors.