Christopher Patty, DNP, RN, CPPS

Medication Safety Specialist

Kaweah Delta Medical Center

Visalia, California

Keeps nurses/patients together during medication administration

Allows nurses to practice to the full extent of their training (IOM, 2011)

Avoids waste in all its forms including wasted thought (IOM, 2001)

Reduces the number of distractions and interruptions* that lead to errors

during medication administration

* Novel, Key to Success

After participating in this presentation, the nurse leader will

•Be able to critically evaluate the risks and benefits of discontinuing mandatory double-checking of adult SQ insulin doses in their practice setting

•Be encouraged to take action on the above evaluation

•General Acute Care Hospital between Fresno and Bakersfield

•Licensed bed capacity 627

•110,000+ doses SQ insulin annually

•Celebrated 1 year* of voluntary DC July 9

•Successfully MERP** Survey June 2015

•FT Med Safety PharmD and DNP

•“A” Hospital Safety Score

•KD has every challenge imaginable; If we did it you can too!

*Almost 2 years on pilot renal unit with 1700 SQ insulin doses/month

**2013 MERP Goal

(Viewer Discretion Advised)

You are a Med/Surg RN in a California GACH

•Your patient is Mr. P., a 55 year-old Type II diabetic who weighs 275 pounds and is highly insulin resistant

•Your hospital has mandatory legal minimum nurse : patient ratios

•Your hospital has a legally mandated Medication Error Reduction Plan

•Your hospital has nurse-driven POC testing and hypoglycemia treatment protocols

•An MD has ordered 1 unit of SQ Novolog using a CPOE system

•The order is reviewed prospectively by pharmacist

•A vial of insulin is dispensed by an automated cabinet

•Using a BCMA system at the bedside, 5-9 “rights” are verified

•Immediately before administration, the SQ insulin dose is double verified with a 2nd registered nurse who you interrupted in the middle of her medication pass two rooms down the hall

9 year old, 6 units Lantus, SQ self-injection

https://youtu.be/cN28k98gC2c

6 year old, insulin pen, SQ self-injection

https://youtu.be/O6ucuyM0y8Y

3 year old, insulin pen, SQ self-injection

https://youtu.be/ZKf9HL2AVrs

Perceived safety benefit: “We can’t go backward on safety practices.”

Risk Aversion: “What would we say to a patient we harmed? What if they sue us?”

Beneficence: “If we prevent one error, it’s worth it.”

Resistance to change: “Change is good, you go first!” – Dilbert

Waiting for the Ideal Evidence

•Meta-Analyses or Systematic Reviews of Randomized Controlled Trials

•Of the results of discontinuing mandatory DV of SQ insulin

•In GACH’s in California

•Not likely to happen

•Need to consider EBP vs PBE

•All evidence comes from research

•Ignorance of Practice-Based Evidence

•“If it isn’t proven in a randomized controlled trial, it should never be done”

•Evidence dictates practice

•Some things aren’t going to be studied using traditional research methods (e.g. RCT of parachute use)

•If a 3 year old can, an RN probably can

•If you do something 125,000 times with a good result, you have generated some evidence

•Integrative Review: Insufficient evidence to support or refute practice of double checking administration (Crawford, 2013) •Systematic Review: Same conclusion as Crawford (Alsulami, 2012) •DV is inconsistently practiced (Brannan, 2010) •DV becomes superficial routine task (Smetzer, 2003) •Errors occur despite DV (Armitage, 2008)

•DV can reduce errors if done correctly; •Two clinicians separately check; •Alone and apart from one another; •Without influencing each other; •Then compare results for each process step •And utilize a checklist

•Downside underappreciated, cost acknowledged (Crawford), distraction/interruption factor not addressed

•Staff aren’t really doing independent double verification of SQ insulin

•Staff really were distracting themselves and interrupting each other during the DV process

•DV = second RN badge scan, treated as a mindless rote task, workarounds abound

•Staff cannot articulate prevented errors

•Every SQ insulin error has been in the mandatory DV era (50 years for KD)

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

•It’s expensive

•Nurses hate it…“the hospital is great at adding things, but they never take anything away”

•Patients aren’t crazy about it either

•Staff are doing it right

•It’s preventing errors

•It’s better than nothing

•It’s mandated by ISMP, Title 22, Joint Commission, CMS, etc.

•Kaweah Delta is alone in CA

“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.” –M. Cohen, April 2013 “Independent double-checks must be strategically placed for just a few high-alert medications” –Cohen, 2014

•2013 MERP Goal: Reduce Distractions & Interruptions During Med Administration

•RN survey indicated that other RN’s were the top source of interruptions

•Observations revealed SQ insulin DV as major source of interruptions by other RN’s

•Discontinuing SQ insulin DV became the primary strategy for the MERP goal

•Obtained support from CNO, Nursing and Pharmacy leaders

•Identified pilot unit, 1700 doses/mo, quit “cold turkey”

•Allowed RN’s to override BCMA requirement for 2nd scan

•30 day trial on 4N became 270 days, then house wide

•60 days in, all units had at least some RN’s “cheating”

•Patient Safety/Satisfaction •No change in glycemia profiles pre- and post- intervention (no change in mean BG)

•Fewer procedural failures and clinical errors

•No change in self-reported ADE pattern

•Improved HCAHPS scores (up 2 points since 10/13)

•Nurse Satisfaction •Reduced interruptions, especially during medication passes (95% - 14%)

•More time with patients

•RN confidence in process (95% no safety risk)

•Cost Avoidance •Waste reduction (workflow simplification)

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

9 RN’s giving 20 SQ insulin doses from 0730-0830 (36 bed unit)

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

Interruption is something we do to each other...”Hey, can I get you to check this insulin with me?”

Forcing Functions

Constraints

Automation

Computerization

Protocols & Order Sets

Double Checks

Rules and Policies

Education

Fixing People

Fixing Systems

•Discontinuing mandatory DC of SQ insulin is a Forcing Function

•Wearing yellow sashes, orange vests, red hats are weaker strategies

•Double checking is weaker still

•Asking nurses to be careful is the weakest yet

•110,000 DV episodes annually

•Half of DV episodes result in an interruption

•One interruption increases error risk by 12.7%

•Many prevented ADE @ $8750/ea (IOM, 2006)

•85 hours RN time/month saved on 36-bed pilot renal unit (1700 doses, 3 minutes RN time/dose

•3,600 RN hours (2 FTE) annually hospital wide (approx 4 FTE/1000 beds)…80K beds in CA…

•$45/hr + 30% benefits = $210K

•How much indirect cost?

•Number of doses of SQ insulin administered

•Number of incident (ADE) reports r/t insulin

•Number of doses of D50W, glucagon

•POC blood glucose data (n, mean, SD, 95%CI) for pre-post intervention comparisons

• % SQ insulin DV resulting in an interruption

•RN time needed to perform double checks

•Salary and benefit costs for RN staff

Double-Checks for Medications: A Summary of the Evidence Cecelia L. Crawford, RN, DNP; © Kaiser Permanente, SCAL Regional Nursing Research Program, January 30, 2013

This excellent integrative review was performed by Dr. Cecelia L. Crawford, an ACNL member. The review is comprehensive and beautifully constructed, including levels of evidence for individual studies examined. It includes a

discussion of monetary implications of double checks. The review does not specifically address insulin, nor does it address distraction or interruption as a

consequence of double check activity.

Double checking the administration of medicines: A systematic review. Zayed Alsulami, Sharon Conroy, Imti Choonara. Archives of Diseases in Childhood, 2012; 97:833-837.

This systematic review was conducted in the U.K. and includes studies of both children and adult double check efficacy. The review does not specifically

address insulin, nor does it address distraction or interruption as a consequence of double check activity.