Abstract
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.