Reducing Insulin Errors in a Pediatric Hospital

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A medication error is defined by the Agency for Healthcare Research and Quality as “an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication”. Medication errors cause significant morbidity and mortality, and contribute to excessive health care spending. Pediatric patients can have up to three times the medication error rate of adults, leading to 7,000 deaths annually. The aim of this study was to identify opportunities to improve insulin safety at the Nemours Children’s Hospital, Delaware. The quality improvement methods employed during this study included the use of process mapping and failure mode and effects analysis (FMEA). Twenty-one multidisciplinary team members convened to map the process of a patient with an established diagnosis of diabetes mellitus presenting with diabetic ketoacidosis from their presentation to the emergency department to their discharge home. Process mapping revealed that nine roles and 71 steps were involved in this process. A total of 103 failure modes were identified in 56 steps of the process, with as many as six failure modes for one step. Risk priority numbers ranged from one to 490. In line with previously published work on insulin errors, failure modes included lapses in communication, misinterpretation of insulin recommendations/orders, and electronic failures.



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