33% of fatal med errors involve insulin therapy
Statistics spur conference seeking solutions
Spurred by studies indicating that 33% of the medical errors that caused death within 48 hours of the error involved insulin therapy, the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology brought together national and international thought leaders in patient safety in endocrinology and metabolic disorders for a consensus conference on Jan. 9-10, 2005, to develop concrete solutions to avoid systemic errors in patient care, focusing on endocrine disorders such as diabetes, osteoporosis, and thyroid disorders.
The statistics were drawn from the research work of Richard Hellman, MD, FACP, FACE, clinical professor of medicine at the University of Missouri-Kansas City School of Medicine, a member of the AACE board of directors and chairman of the conference.
"In 1997, I presented a 14-year study on diabetes outcomes, published in Diabetes Care,"1 Hellman notes. "We’ve done more research since then, and when we looked at people with diabetes who died of a medical error within 48 hours, one-third of those involved error in insulin administration."
This is in keeping with the Joint Commission on Accreditation of Healthcare Organizations’ identification of insulin as one of five high-risk medications, he continues.
"As a convener of the conference, I thought this was timely because medical errors are one of the causes of poor outcomes in diabetes care, and hospitals are one of the core care areas." Some data also were presented at the conference on osteoporosis, Hellman adds, "And it showed a big problem there as well."
The conference produced a wide range of recommendations on how to prevent patients from becoming sicker or dying as a result of medical errors complicating their illness (see the AACE web site, www.aace.com), but Hellman cites three areas that he says hold particular importance for quality managers:
- the use of computers;
- teamwork;
- education.
"When you use computers to capture more information, it also prevents loss of information, which we identified as a leading cause of errors," he explains. "We strongly recommended CPOE [computerized physician order entry]. In the outpatient setting, we are very strong on wanting electronic health records to be used widely; there’s tremendous power there, too, to prevent loss of information."
The health care industry, he notes, still lags behind others when it comes to technology. "You can go into any store anywhere and whip out a credit card, and they can determine if it’s valid; but if you go to an ER anywhere, the odds are they can’t access your information. This is extraordinary for the second biggest industry in the country," Hellman asserts.
The second key issue is building, valuing, and training teams, he adds. "We must collectively value safety. In order to have teamwork that works, you probably need to have more training, more time, more review of what you’re doing, more observing what’s been done, and more measuring, — all that, of course, takes more time, more resources, and more money."
It’s worth it, however, when you consider what can happen when teamwork breaks down. "Here are two examples," Hellman offers. "In one, a doctor orders insulin; the nurse gives the proper dose; the patient receives it and then is whisked away by transportation for a test, but did not get to eat. Or the patient gets the right dose but then the food tray never arrives."
Situations like these occur all too often, he says. "Two of the more common adverse drug events are due to insulin. Who’s talking to whom? [In the previous examples] someone had to communicate to the person coming to take the patient away that they couldn’t do that before he was fed. Or, as another example, if you determine the nursing ratio in the ICU has to be at a certain level to keep errors low, then you need to make sure that level is maintained."
In the area of diabetes management, a lot of the educational efforts are not yet evidence-based, Hellman complains. "What that means is, you really can’t be assured it’s getting the job done," he emphasizes. "In fact, a lot of educational ventures don’t seem to change behavior."
The solution, he says, is a more formal approach. "There have been many advances in cognitive psychology, but we do not seem to be using them," Hellman notes.
Finally, he says, education must be tailored to the patient — in terms of their level of education, ethnic background, and so on.
"Particularly when you’re dealing with certain ethnic groups, if the information is presented in such way that the patient feels demeaned, it’s over," Hellman observes.
"Education is a linchpin [of diabetes management], but how it is given needs to be changed. And we’re not just talking doctor or nurse to patient, but doctor to nurse, nurse to nurse, and so on. It all needs to be well-integrated," he adds.
Reference
1. Hellman R, Regan J, Rosen H. Effect of intensive treatment of diabetes on the risk of death or renal failure in NIDDM and IDDM. Diabetes Care 1997; 20(3):258-264.
Need More Information?
For more information, contact:
• Richard Hellman, MD, FACP, FACE, The American Association of Clinical Endocrinologists, 1000 Riverside Avenue, Suite 205, Jacksonville, FL 32204. Phone: (904) 353-7878.
Spurred by studies indicating that 33% of the medical errors that caused death within 48 hours of the error involved insulin therapy, the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology brought together national and international thought leaders in patient safety in endocrinology and metabolic disorders for a consensus conference on Jan. 9-10, 2005, to develop concrete solutions to avoid systemic errors in patient care, focusing on endocrine disorders such as diabetes, osteoporosis, and thyroid disorders.
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