In this episode, I’ll discuss one hospital’s evolution of the U-500 insulin use process.
Medication errors with U-500 insulin can be serious, and ensuring the safe use of this medication in a hospital setting has presented hospital pharmacies with considerable challenges.
Recently, more tools have become available to facilitate the safe and error-free use of U-500, and one hospital has published the evolution of their insulin U-500 use process in the American Journal of Health System Pharmacy.
They describe the evolution in 3 phases:
In phase one, which began in early 2015, the following enhancements were made:
1. The electronic health record was updated to support the use of U-500 insulin multidose vials with insulin drawn in patient-specific syringes.
2. Both the prescriber and pharmacist were required to document the source of the patient’s U-500 insulin dose in the electronic record, as well as which device the patient used to draw their U-500 insulin dose at home (U-100 insulin syringe, TB syringes, etc). This had to be complete before dispensing could take place.
3. The order could not be verified until all dosing discrepancies were resolved.
4. Prescribers were directed to order this medication through an ordering panel with options to give doses to patients with meals.
5. An alert to the physician was put in place during order entry recommending that the prescriber consult with endocrinology before placing the U-500 order.
In phase two, which began in mid 2017, the following enhancements were made:
1. With the availability of U-500 syringes, dispensing was moved toward drawing patient-specific doses in U-500 insulin syringes instead of tuberculin syringes.
2. With this change, the EHR was switched to show the nurses the amount of units being administered rather than the volume.
3. A passive warning on the MAR was provided to the nurse in the form of a warning message that noted the lack of a safety needle mechanism on the U-500 insulin syringe.
In phase three, which began in late 2020, the following enhancements were made:
1. The hospital’s formulary system switched to using patient-specific U-500 insulin pens.
2. Because these pens can only adminster in 5 unit increments, an automatic dose-rounding policy was implemented. The policy was to round down to the nearest 5 unit increment. For example, 64 units would automatically be rounded down to 60 units.
3. A detailed workflow was added to detect during the ordering verification process if the patient had received any dose of U-500 insulin within the past 2 days. If so, the pharmacist was prompted to ask the nurse if a new pen was required.
4. A passive warning on the MAR was provided to the nurse to alert them to the fact that U-500 is a high-alert medication.
Throughout the implementation of these phases, the hospital utilized various communication methods to physicians, nurses, and pharmacists including web-based reference guides, email communication, and staff huddles.
Although reporting of errors is voluntary, the hospital did notice a decrease in reported errors surrounding U-500 insulin with the implementation of these phases.
These steps represent a thorough approach to improving the safety of the U-500 insulin medication use process and other hospitals can benefit from considering whether any methods in this published report could be implemented locally.
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