Poster Presentation Australian Diabetes Society and the Australian Diabetes Educators Association Annual Scientific Meeting 2016

Diabetes related medication errors:  An analysis of Nepean Blue Mountains LHD IIMS report (#349)

Irene Kopp 1 , SiSi Zhou Zhou , Nirusha Karunaratne , Bradley Marney 1
  1. Nepean Hospital, Penrith, NSW, Australia

Introduction: Poorly controlled diabetes in hospital has quality of care, patient safety, length of stay and cost implications. Although it is estimated that 50% of adverse events are preventable, 1% of the total health budget is spent on management of medication errors in hospitals ($500 million/year). Insulin usage in acute care accounts for about 15% of high risk incidents.

We performed a retrospective review of diabetes medication errors collected from the Nepean Blue Mountains Local Health District (NBMLHD) Incident information management system (IIMS) data. The purpose was to identify the source of diabetes related medication errors, to categorise these errors and to determine their frequency. We correlated this data to interventions that have been introduced to improve safety and efficiency of insulin usage.

Methods: Information collected from the NBMLHD IIMS and Staff-Health-Databases January2012-August2015. Errors categoried by type: prescribing, administration, equipment, storage/waste, inter-ward transfer and insulin-dextrose-infusions. Adverse events recorded including hypoglycaemia, hyperglycaemia, SAC and NSI’s.


Errors related to insulin:

  • Administration: omitting or incorrect timing of doses
  • prescribing: insulin not charted, incorrect insulin.
  • insulin-dextrose-infusions: not adhering to protocol, mismatching fluid lines.
  • Lack of insulin availability: insulin substituted, omitted or delayed administration.
  • Adverse-outcomes were not always specified however hypoglycaemia was one adverse-outcome relating to insulin-dextrose-infusions.
  • Since the mandatory use of syringe drivers for all insulin-infusions there has been one error.
  • Education provided to staff regarding correctly charting Humalog/HumalogMix, since which there have been no more reported prescribing errors.
  • NSI’s were directly associated with use of disposable-pens, education packages were initiated, no further NSI's reported.

Conclusion: Commonly occurring insulin errors include: administration of insulin, prescribing the correct insulin/insulin routine and the correct operation of insulin-dextrose infusions. Identification of areas of deficit has allowed targeting of resources to overcome them, as demonstrated by the impact of interventions that have been implemented.