Reducing Insulin Administration Errors: The Independent Double Check

1. Reducing Insulin Administration Errors:The Independent Double Check Warren Prokopiw, BSc, BSP, M Eng Cynthia Turner, BPharm Michele Babich BSc(Pharm), MHSA

2. Background • Accreditation Canada • verification processes for high risk activities1 • Institute for Safe Medication Practices • independent double check for high alert medications2 • BC Patient Safety and Learning System • Voluntary reporting system for trend analysis • Known to under-report actual rates3

3. Background • Independent Double Checks (IDCs)4 • Second practitioner verifies a procedure • No communication of expected result from first practitioner • Removes bias • Maximize catching errors

4. Objectives • Primary • To determine which medication has the highest administration events within VIHA • To quantify the change in events occurring after implementation of independent double checks • Secondary • To investigate if simplifying event documentation increases the rate of voluntary reporting

5. Methods • Review of historical PSLS reports

6. Methods

7. Methods

8. Results • Event/Dose contingency table and rates • p = 0.0446 • Missed doses not included in the study n=6

9. Results Trial Pre and Post IDC Events

10. Conclusions • Institution of independent double checks significantly reduced the number of insulin events per dose administered compared to pre-implementation • A good catch demonstrated IDCs work • Simplification of event documentation did not increase the rate of voluntary reporting • In the future, we plan to expand independent double checks for insulin administration throughout VIHA

11. Error Reporting

12. References • Accreditation Canada ROP Handbook 2011;28 • ISMP Canada Safety Bulletin 2005;5(1) • Classen D QualSaf Health Care 2005;14 221–226. • VIHA Medication P&P D.22

13. Thank you!