1. Modic, Mary Beth DNP, RN
  2. Albert, Nancy M. PhD, RN
  3. Sun, Zhiyuan MS
  4. Bena, James F. MS
  5. Yager, Christina BS
  6. Cary, Theresa MSN, RN
  7. Corniello, Amanda MSN, RN
  8. Kaser, Nancy MSN, RN
  9. Simon, Julie MSN, RN
  10. Skowronsky, Catherine MSN, RN
  11. Kissinger, Brian BSN, RN


OBJECTIVE: The aim of this study was to examine the effectiveness of a subcutaneous insulin double-checking preparation intervention on insulin administration errors.


BACKGROUND: Insulin accounts for 3.5% of medication-related errors. The Joint Commission and Institute for Safe Medication Practices recommend a 2-nurse double-checking procedure when preparing insulin.


METHODS: This study used a randomized, controlled, nonblinded, intent-to-treat methodology.


RESULTS: In total, 266 patients were enrolled, and over 4 weeks of data collection, there were 5238 opportunities for insulin administration. Overall, 3151 insulin administration opportunities had no errors; the double-checking group had more no-error periods than usual care. Of error types, wrong time was predominant, but less prevalent in the double-checking group. Omission errors were uncommon and occurred less in the double-checking group.


CONCLUSIONS: The subcutaneous insulin double-checking preparation procedure led to less insulin administration errors; however, timing errors were most prevalent and are not resolved with double-checking interventions.