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:
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.