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      Chapter 4

       Insulin Errors in the Inpatient Setting

      Richard Hellman, MD, FACP, FACE¹

      ¹Clinical Professor of Medicine, University of Missouri-Kansas City School of Medicine; Medical Director, Heart of America Diabetes Research Foundation, North Kansas City, MO. DOI: 10.2337/9781580406086.04

      DOI: 10.2337/9781580406086.04

      Introduction

      Insulin therapy is the best and most powerful tool at our disposal for the control of glucose levels in the inpatient setting, but errors in providing this crucial therapy not only diminish the effectiveness of this therapy, but also, in some cases, cause in-hospital morbidity and even mortality. It is for this reason that the Joint Commission on Hospital Accreditations (JCOHA) considers insulin one of the five “high-alert” medicines that are most commonly associated with serious injury or death.¹ Numerous studies have shown that errors in insulin therapy are a frequent cause of excessive morbidity and mortality.² In one study, in the inpatient setting, one-third of the deaths of patients with diabetes resulting from a catastrophic error were due to errors in insulin therapy.³

      This chapter offers explanations for why errors in insulin therapy occur, discusses the types of errors, and provides a practical guide to strategies that have been shown to be useful to both reduce the frequency of errors and prevent injuries resulting from errors related to insulin therapy in the inpatient setting.

      The chapter looks at the problems from three different, but overlapping, perspectives. The first perspective takes a systemic approach—looking at the dominant role that organizational and systems issues play in the development and continuation of higher rates of errors in insulin therapy. The second perspective follows the individual providers of health care, the physicians and nurses and other key hospital personnel, and pays special attention to a relatively underdiscussed but crucial aspect: diagnostic errors and their role in injurious errors in insulin therapy. The third perspective examines the prevention of specific types of errors, looking at the type of medication errors in insulin therapy described in a recent publication by the American Society of Health-System Pharmacists (ASHP).⁴ The chapter concludes with a list of proposals to reduce the frequency of errors in insulin therapy and to reduce risk of any morbidity and mortality from such errors.

      Background

      Despite overwhelming evidence of the need to reduce significant hyperglycemia and avoid hypoglycemia during the routine use of insulin in hospitals,^5,6 glycemic control remains suboptimal in many inpatient settings. In some cases, as a result of errors in insulin therapy, glycemic control deteriorates during a hospital stay. For example, in 2007, the Centers for Medicare and Medicaid Services (CMS) reported data on so-called never events related to glycemic control, that is, disorders of glycemic control that should never have their onset in a hospital. They identified three such events: hospital-acquired diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic syndrome (HHS), and severe hypoglycemia. They reported that during a one-year period there were 15,848 documented such events. Of these, 72.4% were episodes of DKA that began during an inpatient stay, 20.5% were significant cases of HHS, and 7.1% were cases of severe hypoglycemia resulting in coma. In 2008, CMS announced it would not pay for hospital stays in which those never events occurred. Yet, some data from several states show that these never events in glycemic management are still occurring in U.S. hospitals at a rate of close to half of the 2007 rates.⁷

      Few experts in hospital medicine were surprised that the threat of nonpayment by CMS did not have a greater effect on reducing the frequency of these so-called never events. Hospitals are extraordinarily complex structures, and the complexity of care needed for patients who need improvement of their glycemic control often stresses the systems of care present in the hospitals and reveals their shortcomings.⁸ Changes in the present hospital systems of care will be needed if we are to make in-hospital care safe for the patient with diabetes.

      Systemic Issues in the Development of Errors in Insulin Therapy

      To understand why some of the errors occur so often and why it is so hard to prevent them, it is important to look at systemic issues that play an important role in the development and persistence of errors in insulin therapy over time. It may seem counterintuitive, but some decisions made far from the bedside, often termed the “blunt end of care,” have a profound effect on the chance that errors will occur. The shortage of nursing personnel is one such example. Errors involving nurses at