What action during hand-off would have prevented hypoglycemia in a diabetic patient due to a miscommunication about insulin glargine (long-acting insulin) dosage?

From the Guidelines

The closed-loop communication technique would have most likely prevented this patient-safety error. This approach involves the receiver of information repeating back what they heard to confirm accuracy, which would have allowed the ICU physician to correct the misheard insulin dose before an error occurred. In this case, if the floor physician had repeated "60 units of long-acting insulin" back to the ICU physician, the ICU physician could have immediately clarified that the correct dose was 16 units, not 60. This verification process is particularly important for high-risk medications like insulin where dosing errors can lead to serious consequences such as severe hypoglycemia, as highlighted in recent studies 1. The patient's lethargy and hypoglycemia resulted directly from receiving nearly four times their usual insulin dose (60 units instead of 16 units).

Some key points to consider in preventing such errors include:

• Insulin is one of the most common medications causing adverse events in hospitalized individuals, with errors in insulin dosing, missed doses, and administration errors being relatively frequent 1.
• A hypoglycemia management surveillance protocol should be adopted by all health systems, including a plan for identifying, treating, and preventing hypoglycemia for each individual 1.
• While other quality improvement methods like failure mode analysis and root cause analysis are valuable for system-level improvements, they wouldn't have prevented this immediate communication error. Similarly, the teach-back method, while useful for patient education, wouldn't address the physician-to-physician communication breakdown that occurred during this handoff.

The use of closed-loop communication is supported by the most recent evidence, which emphasizes the importance of accurate and clear communication in preventing medication errors, especially with high-risk medications like insulin 1. By prioritizing this approach, healthcare providers can significantly reduce the risk of adverse events and improve patient outcomes.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Safety Event

The patient-safety event described involves a medication error due to a communication breakdown during hand-off. The ICU physician stated that the patient takes 16 units of long-acting insulin, but the floor physician heard "60" units, resulting in the patient being administered an excessive dose of insulin and subsequently becoming lethargic and hypoglycemic.

Actions to Prevent Patient-Safety Events

To prevent such events, several strategies can be employed:

• Closed-Loop Communication: This involves verifying that the message sent is the same as the message received, ensuring that both parties are clear on the information being communicated 2.
• Teach-Back Method: This method involves having the recipient of information repeat back what they have understood to ensure accuracy and clarity.
• Failure Mode and Effects Analysis: This is a proactive approach to identify potential failures in a process and assess their impact.
• Root Cause Analysis: This involves identifying the underlying causes of an error or event to prevent recurrence.

Most Likely Action to Prevent the Event

The action that would have most likely prevented this patient-safety event is Closed-Loop Communication. By using closed-loop communication, the floor physician would have repeated back the information to the ICU physician to confirm the correct dose of insulin, preventing the miscommunication and subsequent error 2.

Barriers to Reporting Patient Safety Events

Barriers to reporting patient safety events include time constraints, fear of reprisal, and a lack of education on reporting procedures 3. Incentives for reporting include valuing patient safety event reporting and providing feedback and visible changes resulting from reports.

Insulin Administration

Insulin administration, particularly the use of long-acting insulins like insulin glargine, requires careful dosing and monitoring to prevent hypoglycemia 4. The development of insulin radioimmunoassay has significantly improved the measurement of insulin levels, aiding in the management of diabetes 5.