“Discontinuing Mandatory Double Verification of Subcutaneous Insulin Improves Patient Safety and

Nurse Satisfaction”

Christopher Patty, DNP, RN, CPPSKaweah Delta Medical Center

Visalia, California

Commonly Overheard…..

“The hospital is great at adding things for nurses to do, but they

never take anything away”

A 12-Step Program for Ending Your Addiction to Double Verification of

SQ Insulin

Addiction (def.) “Compulsive engagement in rewarding

behavior despite adverse consequences”

Adverse Consequences?•The DV process induces many distractions, interruptions, procedural failures and clinical errors

•Nurses hate it

•Patients aren’t crazy about it either

Distraction vs. Interruption

Distraction (antonym: concentration) is something I do to myself “…I need to find another nurse to DV this insulin”

Interruption is something I do to someone else…”Hey, will you check this insulin with me?”

The Evidence for Double Verification•DV can reduce errors by 30% if done correctly•Two clinicians separately check;•Alone and apart from one another;•Then compare results;•For prescribing, dispensing and verifying

•DV is inconsistently practiced (Brannan, 2010)•Errors occur despite DV (Armitage, 2008)•DV becomes superficial routine task (Smetzer, 2003)

Reality Check…

•Staff aren’t really doing independent double verification•Staff treat DV as a mindless robotic rote task•Deviance from ideal practice has been normalized•Staff cannot articulate prevented errors•Every insulin error has been in the DV era•40% of SQ insulin doses are 1 unit

It Used to Make Sense But Then Almost Everything Changed

•All our orders were in paper charts•We did the transcribing/decoding•Before pharmacist’s prospective review of orders•Before automated dispensing cabinets•Before barcode medication administration•Before POC blood glucose testing•Before 1/3rd of our patients were diabetic

ISMP Recommendations 2009-2014“Our safety consulting staff recommends independent double checks for IV but not SQ insulin, because these almost certainly will not be properly conducted due to volume of doses needing a check”

“We are fine if any individual nurse giving subcutaneous insulin wants to ask for a check by a second individual, but we don't believe it should be a requirement in most situations.” – Michael Cohen, April 2013

“Independent double-checks must be strategically placed for just a few high-alert medications”

So…why are we still doing it?•It’s required by JCAHO, Title 22, CMS, etc•That’s the way I was trained•Insulin is a “high alert” medication.•Patients die from insulin overdoses!•Two heads are better than one•Better to do something than do nothing.•Everyone else is doing it•We’ve always done it that way•It’s policy•We don’t want to stop for the wrong reasons

Improves Patient Safety

•Keeps nurses and patients together•Allow nurses to practice to the full extent of their licensure (IOM, 2011)•Avoid waste in all its forms including wasted thought (IOM, 2001)

Improves Nurse Satisfaction

•Reduces the number of distractions and interruptions during medication administration

Prescribing Drives Insulin Timing

SQ Insulin Administration Timing

1 2 3 40

20

40

60

80

100

120

140

160

140

88

70

100

Volume of SQ Insulin Doses vs. Time of Day, 1 Week/Unit

Combined with Diabetes Prevalence

The Bottom Line…

“When you need me to double-verify your insulin, I’m in the middle of giving mine”

•Patient Safety•No change in glycemia profiles pre- and post- intervention•No change in self-reported ADE pattern

•Nurse Satisfaction •Reduced interruptions, especially during medication passes•More time with patients•RN confidence in process

•Cost Avoidance•Waste reduction

Desired Outcomes of Change

What we did...•Explained rationale for change•Reducing distractions/interruptions

•Made DV voluntary for SQ insulin•A few continue DV

•Instructed RN in procedure for BCMA override, documentation•Observed RN give SQ insulin dose•Follow-up visits over a month

Two Ways to Improve a Process (IHI)

1. Reduce the number of steps in the process.

2. Increase the reliability of individual process steps.

Process (def.) A series of steps leading to a result

Process A Process B Process C Process D

Step 1 99% 99% 99% 99%

Step 2 --- 99% 99% 99%

Step 3 --- --- 99% 99%

Step 4 --- --- --- 99%

Overall Reliability 99% 98% 97% 96%

Systems Improvement Strength Hierarchy

Forcing Functions Constraints

Automation

Computerization Protocols & Order Sets

Double Checks Rules and PoliciesEducation

Fixing People

Fixing Systems

Total Hours in DV Activity (1.5 - 3” per DV event) 112,516 events 2812 - 5625

Estimated Interruptions (4:1 ratio med pass : interruption) 28,129

Estimated Clinical Errors Induced by DV (+12.7% risk per) 3772

Annual Cost of DV-Induced Error (1% harmful errors, $8750 ea) $330,500

Interruptions during medication pass, self-reported (pre) 95%

Interruptions during medication pass, self-reported (post) 14%

Agree/strongly agree discontinuing DV ↑ patient safety risk 5%

Results

References

Questions?