What Are Hospitals Using Now?
Currently, some hospitals are utilizing the following solution:
Independent double check. This is a human double check of the insulin dosage by nurses and has been proven to be ineffective. The Institute for Safe Medication Practices (ISMP) States in their research that, " A manual independent double check of high-alert medications is a strategy that has been widely promoted in healthcare to help detect potentially harmful errors before they reach patients.(1-3) However, independent double checks used as a risk-reduction strategy have long been disputed as well as misused in healthcare. Its use has been a source of stress for busy prescribers, pharmacists, and nurses who are short on time. Its impact on safety has been questioned by those who rarely find mistakes during the checking process. Its inconsistent use and variability in how the task is carried out has rendered it incapable of detecting many errors. Its overuse as a risk-reduction strategy for high-alert medications has been called to task given its status as a weak error-reduction strategy, particularly if it is the only safeguard in place. Its frequent misuse as a quick fix for an ailing medication use system has been the bane of managers who have investigated serious errors that have reached a patient due to a failed double-check process." Nurses also state in round-table discussions that they just don't have time to do it. In addition, there are nursing/staffing shortages so many nurses are working longer shifts.
The Problem to Solve:
According to a recently published study, as many as 440,000 medical errors result in death in U.S. hospitals every year. Thirty five percent of these errors are due to medications. Insulin is the most common cause of medication-related patient harm, being implicated in 33% of medication error related events, including dosing errors causing hypo or hyperglycemia resulting in prolonged length of stay, morbidity and mortality.* If you are a diabetic in the hospital, and you die of a medical error, there is a 33% chance that error is related to your insulin administration.** Deadly medical mistakes can stem from many issues, including labels that look alike or sound alike; incorrect preparation of an injectable dose by mixing up mL's and units; or simply giving a dose to the wrong patient in a two-bed room. Nurses are busy and often understaffed. All pill based medications in the hospital are currently digitally verified at administration. Insulin is not, because nothing could easily measure liquid medication under 1mL until now. We have closed this gap in patient safety. Why leave patient care open to human mistakes that could easily be prevented with our technology?
* Katelyn Brown, Purdue, 2008
** Hellman R, Regan J, Rosen H. Effect of intensive treatment of diabetes on the risk of death or renal failure in NIDDM and IDDM. Diabetes Care 1997; 20(3):258-264
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The problem is no current effective way to verify the type and amount of insulin administered in a hospital setting. There is also no way to verify that the medication is administered to the correct patient. This leaves patient safety too vulnerable to human error.
The good news is that hospitals have invested heavily in their Electronic Health Records (EHR), which can significantly improve patient safety. For example, for pill medications, EHR’s verify the dose of the drug. The drug is administered to the correct patient by matching the doctor’s order in the EHR with the bar code printed on the medication package. When the nurse scans the correct drug and dose for the correct patient, she or he receives confirmation the drug is safe to administer. Scanning the medication also automatically documents administration in the EHR. However, dosage of insulin remains a significant exception to this important safety feature. To address this risk, many hospitals use a double check system, but according to the Institute for Safe Medication Practice (ISMP), “It’s inconsistent use and variability in how the task is carried out has rendered it incapable of detecting many errors.”
Here is a real-life example: A veteran ICU nurse was caring for a patient on an intravenous insulin infusion. The doctor ordered an extra dose of 7 units of insulin based on the most recent blood sugar. As she prepared the dose, the nurse confused the concentration of insulin in the infusion (1 unit/ml) with the concentration in the manufacturer vial (100 units/ml). As a result she filled a syringe with 7 mL (700 units) instead of 7 units (0.07 mL). The EHR did not prevent the error and the dose was administered. It’s shocking that these kinds of errors can be made by people who are dedicated to helping others, but “To err is human” and no matter how well trained we are, we will make errors. There is more to it than training and attitude. We've identified a huge gap in hospital safety and developed a medical device and software that makes nurses’ jobs less stressful and hospitals safer for patients.