title: Does an Insulin Double-Checking Procedure Improve Patient Safety?
abstract: The aim of this study was to examine the effectiveness of a subcutaneous insulin double-checking preparation intervention on insulin administration errors.
  
  
  
  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.
  
  
  
  This study used a randomized, controlled, nonblinded, intent-to-treat methodology.
  
  
  
  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.
  
  
  
  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.
authors: Author Affiliations: Clinical Nurse Specialist (Dr Modic), Office of Nursing Education and Professional Practice Development, Cleveland Clinic; Associate Chief Nursing Officer (Dr Albert), Office of Nursing Research and Innovation, Biostatistician (Mr Sun), Quantitative Health Sciences, and Biostatistician (Mr Bena), Quantitative Health Sciences, Cleveland Clinic Health System; and Volunteer (Ms Yager), Department of Volunteer Services, Clinical Nurse Specialists (Mss Cary, Corniello, Kaser, Simon, and Skowronsky), and Clinical Instructor (Mr Kissinger), Office of Nursing Education and Professional Practice Development, Cleveland Clinic, Ohio.
authors: Mary Beth
authors: MB
authors: Modic
authors: Nancy M
authors: NM
authors: Albert
authors: Zhiyuan
authors: Z
authors: Sun
authors: James F
authors: JF
authors: Bena
authors: Christina
authors: C
authors: Yager
authors: Theresa
authors: T
authors: Cary
authors: Amanda
authors: A
authors: Corniello
authors: Nancy
authors: N
authors: Kaser
authors: Julie
authors: J
authors: Simon
authors: Catherine
authors: C
authors: Skowronsky
authors: Brian
authors: B
authors: Kissinger
mesh_terms: D000328:Adult; D003920:Diabetes Mellitus / Q000188:drug therapy* / Q000451:nursing; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D007279:Injections, Subcutaneous; D007328:Insulin / Q000008:administration & dosage*; D057194:Intention to Treat Analysis; D008297:Male; D008508:Medication Errors / Q000451:nursing / Q000517:prevention & control* / Q000706:statistics & numerical data*; D008875:Middle Aged; D061214:Patient Safety / Q000592:standards*; D011897:Random Allocation; D017751:Safety Management / Q000592:standards; D014481:United States
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin