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Concentrated Insulin Nationwide Review
Some initial thoughts

Even with over 1.4 million events in the CHPSO database, fewer than 50 relate to concentrated insulin, underscoring the need for broad collaboration to understand the issues behind this high-risk medication. In February 2017, CHPSO started working with other PSOs and health care delivery systems to take a closer look at the types of incidents that are occurring and see what organizations are doing to prevent these types of incidents from occurring.

Collaborating Organizations include:

  • American Data Network – Arkansas
  • Ascension Health Patient Safety Organization
  • Carolinas HealthCare System
  • Cassatt Patient Safety Organization
  • Center for Patient Safety – Missouri
  • Children’s Hospital Patient Safety Organization
  • Empire State Patient Safety Assurance Network
  • Institute for Safe Medication Practices (ISMP)
  • MHA Keystone Center – Michigan
  • Maryland Patient Safety Center- Maryland
  • Midwest Alliance for Patient Safety PSO – Illinois
  • North Carolina Quality Center (NCQC PSO)
  • University of Nebraska Medical Center (UNMC)
  • Tennessee Center for Patient Safety
  • Texas Hospital Association
  • VA National Center for Patient Safety
  • Virginia Patient Safety Organization
  • Virginia Bon Secours Health System
  • Vizient, Inc.

The goal is to identify the parts of the medication use process that members are struggling with, and come up with a gap analysis and toolkit that addresses the areas in which we identify errors. As part of this, participating organizations will hold safe tables and other meetings with their members. They will also develop and accumulate helpful documents such as procedures, training, checklists, etc.

Initial Thoughts

U-500 insulin is rarely used, and requires either a special U-500 syringe or pen, administration via TB syringe, or use of a U-100 syringe with manual calculations to translate the markings to the correct dose. The only U-500 syringe in the USA market lacks a needle-stick safety device. Hospitals are faced with either stocking U-500 syringes without needle guards for the rare (a few times a year) use, using a non-U-500 syringe, obtaining a U-500 insulin pen for the patient, or transitioning the patient to U-100 when in-house.

The rarity of use and the calculation challenges posed by non-U-500 syringes appear a common component of many of the events. We are engaged in a collaborative analysis of all the events with the other participating organizations and will have a full report later. There were total 488 events contributed by the participating organizations.

Harm Level (488 events total):

  • 0.002% Death
  • 2% Severe Harm
  • 15% Moderate Harm
  • 40% Mild Harm
  • 15% No Harm
  • 28% Not mentioned

Below is a sampling of the event report narratives in the combined database:

  • A patient was on U-500 insulin. Dose at noon was 0.08 ml/40 units sq. Charted as 0.8 ml which would be 400 units. The patient became hypotensive and lethargic requiring medical intervention to raise glucose level repeatedly throughout the evening resulting in transfer MICU.
  • A nurse drew up patient’s concentrated insulin dose; noticed the dosage ordered was for “40 units/0.8 ml”. Concentrated regular insulin is 500 units/ml so 40 units is equal to 0.08 ml, not 0.8 ml. Order was changed to the correct concentration. It was unclear as to what dose patient received for previous 4 doses. Blood sugars were stable.
  • A patient was ordered U-500 insulin 15 units AC breakfast and 20 units AC dinner per patient and patient’s home record. Patient was using U-100 syringe. Actual dose upon clarification was 75 units (15 units on U-100 syringe) AC breakfast and 100 units (20 units on U-100 syringe) AC dinner.
  • A vial of U-500 was in the medication refrigerator because a patient had been on it. The vial was probably dispensed with the patient’s name label on the box. The box was opened and discarded, and the patient was discharged. The vial was left in the refrigerator. A Nurse saw the Humulin R vial, drew up the dose and administered. Another nurse saw the vial and read the warnings out loud. The nurse realized the error and called the physician. The patient was monitored and was okay. Upon further review, there is a possibility that several other patients received doses from the vial, two possibly transferred to ICU for severe hypoglycemia. The hospital completed a root cause analysis, final report pending. Part of the solution is the U-500 vials will never leave the pharmacy. The hospital will draw up doses when ordered.
  • Upon typing “insulin R” into our CPOE system one gets two options: “Insulin Regular Human” and “Insulin Regular Human Con”. Presumably the part that is cut off refers to concentrated to indicate it is the U-500 insulin. However “Con” could refer to any number of things and in any case that terminology is non-standard and non-specific as to what that option is. Given that they pop up together, it would be very easy to erroneously select the concentrated version. This has already happened.

As the work with the collaborating organizations progresses, CHPSO will keep readers updated.