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Mader JK, Aberer F, Drechsler KS, Pöttler T, Lichtenegger KM, Köle W, Sendlhofer G. Medication errors in type 2 diabetes from patients’ perspective. PLoS One 2022; 17:e0267570. [PMID: 35482748 PMCID: PMC9049508 DOI: 10.1371/journal.pone.0267570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Drug errors pose a major health hazard to a number of patient populations. However, patients with type 2 diabetes mellitus seem especially vulnerable to this risk as diabetes mellitus is usually concomitant with various comorbidities and polypharmacy, which present significant risk factors for the occurrence of drug errors. Despite this fact, there is little data on drug errors from patients’ perspective. The present survey aimed to examine the viewpoints of patients with type 2 diabetes mellitus regarding their experiences with medication errors, the overall treatment satisfaction, and their perceptions on how a medication error was handled in daily hospital routine. Materials and methods Inpatients at the Department of Endocrinology and Diabetology of the University Hospital of Graz were included in the survey. Out of 100 patients, one-half had insulin therapy before hospitalization while the other half had no insulin therapy prior to admission. After giving informed consent, patients filled out a questionnaire with 22 items. Results Independent of their preexisting therapy, 25% of patients already suffered at least one drug error, whereby prescribing a wrong dose seemed to be the most common type of error. Furthermore, 26% of patients in the non-insulin versus 50% in the insulin group (p = 0.084) were convinced that drug errors were addressed honestly by the medical staff, while 54% in the non-insulin versus 80% in the insulin-group (p = 0.061) assumed that adequate measures were taken to prevent drug errors. Finally, 9 out of 10 patients seemed satisfied with their treatment regardless of their diabetes therapy. Discussion/conclusion The results of the survey clearly showed that patients experienced at least one medication error during hospitalization. However, these errors only rarely led to patient harm. The survey also revealed the value of an honest and respectful doctor-patient relationship regarding patient perception of medication errors and general complaints. Increasing patient awareness on the existing in-hospital error management systems could eliminate treatment-related concerns and create a climate of trust that is essential for effective treatment.
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Affiliation(s)
- Julia K. Mader
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - Felix Aberer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - Kerstin Sarah Drechsler
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - Tina Pöttler
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - Katharina M. Lichtenegger
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - Wolfgang Köle
- Department of General Otorhinolaryngology, Medical University of Graz, Graz, Austria
- Medical Directorate, University Hospital of Graz, Graz, Styria, Austria
| | - Gerald Sendlhofer
- Executive Department for Quality and Risk Management, University Hospital of Graz, Graz, Styria, Austria
- Department of Surgery, Research Unit for Safety and Sustainability in Healthcare, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Medical University of Graz, Graz, Styria, Austria
- * E-mail:
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Kopanz J, Lichtenegger KM, Sendlhofer G, Semlitsch B, Cuder G, Pak A, Pieber TR, Tax C, Brunner G, Plank J. Limited Documentation and Treatment Quality of Glycemic Inpatient Care in Relation to Structural Deficits of Heterogeneous Insulin Charts at a Large University Hospital. J Patient Saf 2021; 17:e631-e636. [PMID: 29432336 DOI: 10.1097/pts.0000000000000465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Insulin charts represent a key component in the inpatient glycemic management process. The aim was to evaluate the quality of structure, documentation, and treatment of diabetic inpatient care to design a new standardized insulin chart for a large university hospital setting. METHODS Historically grown blank insulin charts in use at 39 general wards were collected and evaluated for quality structure features. Documentation and treatment quality were evaluated in a consecutive snapshot audit of filled-in charts. The primary end point was the percentage of charts with any medication error. RESULTS Overall, 20 different blank insulin charts with variable designs and significant structural deficits were identified. A medication error occurred in 55% of the 102 audited filled-in insulin charts, consisting of prescription and management errors in 48% and 16%, respectively. Charts of insulin-treated patients had more medication errors relative to patients treated with oral medication (P < 0.01). Chart design did support neither clinical authorization of individual insulin prescription (10%), nor insulin administration confirmed by nurses' signature (25%), nor treatment of hypoglycemia (0%), which resulted in a reduced documentation and treatment quality in clinical practice 7%, 30%, 25%, respectively. CONCLUSIONS A multitude of charts with variable design characteristics and structural deficits were in use across the inpatient wards. More than half of the inpatients had a chart displaying a medication error. Lack of structure quality features of the charts had an impact on documentation and treatment quality. Based on identified deficits and international standards, a new insulin chart was developed to overcome these quality hurdles.
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Affiliation(s)
- Julia Kopanz
- From the Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz
| | - Katharina M Lichtenegger
- From the Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz
| | | | - Barbara Semlitsch
- From the Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz
| | - Gerald Cuder
- From the Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz
| | - Andreas Pak
- Department of Controlling, University Hospital Graz
| | - Thomas R Pieber
- From the Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz
| | - Christa Tax
- Board of Directors, University Hospital Graz
| | | | - Johannes Plank
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University Hospital Graz, Austria
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Hill A, Francis SJ, Horswill MS, Christofidis MJ, Watson MO. A human factors approach to subcutaneous insulin chart design improves user-performance: An experimental study. APPLIED ERGONOMICS 2021; 94:103389. [PMID: 33647789 DOI: 10.1016/j.apergo.2021.103389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 06/12/2023]
Abstract
Insulin is a high-risk medicine that has been implicated in serious adverse events for hospital inpatients, including medication-error related deaths. Most insulin errors occur during administration, and "wrong dose" is the most common type. A paper-based subcutaneous insulin chart (the "NSIC") was developed for the Australian Commission on Safety and Quality in Health Care, using a range of human factors methods, with the aim of reducing the opportunity for errors. The present lab-based study empirically assessed whether the NSIC's human factors design translates into improved user-performance in the determination of insulin doses, compared with a pre-existing chart. Forty-one experienced nurses and 48 novice chart-users completed 60 experimental trials (30 per chart), in which they determined doses to administer to patients. Both groups determined insulin doses faster, and made fewer dose errors, when using the NSIC. These results support the utility of the usability heuristics employed in developing the chart.
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Affiliation(s)
- Andrew Hill
- Clinical Skills Development Service, Metro North Hospital and Health Service, Herston, Brisbane, Queensland, 4006, Australia; School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia; Minerals Industry Safety and Health Centre, Sustainable Minerals Institute, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia.
| | - Sophie J Francis
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia
| | - Mark S Horswill
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia
| | - Melany J Christofidis
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia; Mater Hospital, Mater Health, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Marcus O Watson
- Clinical Skills Development Service, Metro North Hospital and Health Service, Herston, Brisbane, Queensland, 4006, Australia; School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia; School of Medicine, The University of Queensland, Herston, Brisbane, Queensland, 4006, Australia
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Kopanz J, Lichtenegger KM, Koenig C, Libiseller A, Mader JK, Donsa K, Truskaller T, Bauer N, Hahn B, Sendlhofer G, Beck P, Höll B, Sinner F, Feichtner F, Pieber TR. Electronic Diabetes Management System Replaces Paper Insulin Chart: Improved Quality in Diabetes Inpatient Care Processes Due to Digitalization. J Diabetes Sci Technol 2021; 15:222-230. [PMID: 32935559 PMCID: PMC8256067 DOI: 10.1177/1932296820957043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND GlucoTab, an electronic diabetes management system (eDMS), supports healthcare professionals (HCPs) in inpatient blood glucose (BG) management at point-of-care and was implemented for the first time under routine conditions in a regional hospital to replace the paper insulin chart. METHOD To investigate quality of the eDMS for inpatients with type 2 diabetes mellitus a monocentric retrospective before-after evaluation was conducted. We compared documentation possibilities by assessing a blank paper chart vs the eDMS user interface. Further quality aspects were compared by assessing filled-in paper charts (n = 106) vs filled-in eDMS documentation (n = 241). HCPs (n = 59) were interviewed regarding eDMS satisfaction. RESULTS The eDMS represented an improvement of documentation possibilities by offering a more structured and comprehensive user interface compared to the blank paper chart. The number of good diabetes days averaged to a median value of four days in both groups (paper chart: 4.38 [0-7] vs eDMS: 4.38 [0-7] days). Median daily BG was 170 (117-297) mg/dL vs 168 (86-286) mg/dL and median fasting BG was 152 (95-285) mg/dL vs 145 (69-333) mg/dL, and 0.1% vs 0.4% BG values <54 mg/dL were documented. Diabetes documentation quality improved when using eDMS, for example, documentation of ordered BG measurement frequency (1% vs 100%) and ordered BG targets (0% vs 100%). HCPs stated that by using eDMS errors could be prevented (74%), and digital support of work processes was completed (77%). Time saving was noted by 8 out of 11 HCPs and estimated at 10-15 minutes per patient day by two HCPs. CONCLUSIONS The eDMS completely replaced the paper chart, showed comparable glycemic control, was positively accepted by HCPs, and is suitable for inpatient diabetes management.
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Affiliation(s)
- Julia Kopanz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Katharina M Lichtenegger
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Constanze Koenig
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Angela Libiseller
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Julia K Mader
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Klaus Donsa
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Thomas Truskaller
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Norbert Bauer
- Department of Internal Medicine, LKH Hartberg, Austria
| | | | - Gerald Sendlhofer
- Department for Surgery, Research Unit for Safety in Health, Division for Plastic, Aesthetic and Reconstructive Surgery, Medical University of Graz, Austria
| | - Peter Beck
- Decide Clinical Software GmbH, Graz, Austria
| | | | - Frank Sinner
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Franz Feichtner
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Thomas R Pieber
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Austria
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
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Kopanz J, Sendlhofer G, Lichtenegger K, Semlitsch B, Riedl R, Pieber TR, Tax C, Brunner G, Plank J. Evaluation of an implemented new insulin chart to improve quality and safety of diabetes care in a large university hospital: a follow-up study. BMJ Open 2021; 11:e041298. [PMID: 33500281 PMCID: PMC7839871 DOI: 10.1136/bmjopen-2020-041298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To evaluate structure, documentation, treatment quality of a new implemented standardised insulin chart in adult medical inpatient wards at a university hospital. DESIGN A before-after study (3 to 5 months after implementation) was used to compare the quality of old versus new insulin charts. SETTING University Hospital Graz, Austria. PARTICIPANTS Healthcare professionals (n=237) were questioned regarding structure quality of blank insulin charts. INTERVENTIONS A new standardised insulin chart was implemented and healthcare professionals were trained regarding features of this chart. Data from insulinised inpatients were evaluated regarding documentation and treatment quality of filled-in insulin charts (n=108 old insulin charts vs n=100 new insulin charts). MAIN OUTCOMES AND MEASURES The primary endpoint was documentation error for insulin administration. RESULTS Healthcare professionals reported an improved structure quality of the new insulin chart with a Likert type response scale increase in all nine items. Documentation errors for insulin administration (primary endpoint) occurred more often on old than new insulin charts (77% vs 5%, p<0.001). Documentation errors for insulin prescription were more frequent on old insulin charts (100% vs 42%) whereas documentation errors for insulin management rarely occurred in any group (10% vs 8%). Patients of both chart evaluation groups (age: 71±11 vs 71±12 years, 47% vs 42% women, 75% vs 87% type 2 diabetes for old vs new charts, respectively) had a mean of 4±2 good diabetes days. Overall, 26 vs 18 hypoglycaemic episodes (blood glucose (BG) <4.0 mmol/L (72 mg/dL), p=0.28), including 7 vs 2 severe hypoglycaemic episodes (BG <3.0 mmol/L (54 mg/dL), p=0.17) were documented on old versus new insulin charts. CONCLUSIONS The implementation of a structured documentation form together with training measures for healthcare professionals led to less documentation errors and safe management of glycaemic control in hospitalised patients in a short time follow-up. A rollout at further medical wards is recommended, and sustainability in the long-term has to be demonstrated.
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Affiliation(s)
- Julia Kopanz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Gerald Sendlhofer
- Executive Department for Quality and Risk Management, University Hospital of Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Katharina Lichtenegger
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Barbara Semlitsch
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Regina Riedl
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Thomas R Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christa Tax
- Chief Nursing Director, University Hospital Graz, Graz, Styria, Austria
| | - Gernot Brunner
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Chief Medical Director, University Hospital Graz, Graz, Styria, Austria
| | - Johannes Plank
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Bain A, Hasan SS, Kavanagh S, Babar ZUD. Use and validation of a survey tool to measure the perceived effectiveness of insulin prescribing safety interventions in UK hospitals. Diabet Med 2020; 37:2027-2034. [PMID: 32592220 DOI: 10.1111/dme.14351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/26/2020] [Accepted: 06/18/2020] [Indexed: 11/28/2022]
Abstract
AIMS To describe the use and validation of a survey tool to elicit the opinion of hospital pharmacists and medicines safety officers in the UK regarding the perceived effectiveness of strategies to improve insulin prescribing safety in hospitals. METHODS One respondent from each participating organization completed the survey on behalf of the main acute hospital in their trust (n = 92). A five-point Likert scale was used to determine opinion on how effective 22 different interventions were at promoting insulin safety at the respondent's trust. The tool, the Perception of Effectiveness of Prescribing Safety Interventions for Insulin (PEPSII) questionnaire, underwent content validity testing. The reliability was estimated using Cronbach's alpha (α). RESULTS The PEPSII questionnaire demonstrated good reliability (α = 0.867). Outreach team review and mandatory insulin education were the highest-scoring interventions; the insulin passport was amongst the lowest scoring interventions. Most interventions were considered more effective by trusts using them compared to those who didn't, except for self-administration policies, electronic prescribing and the insulin passport. CONCLUSIONS The perceived effectiveness of a variety of insulin prescribing safety strategies in UK hospitals was described by leveraging a purposely developed survey tool. The results describe current levels of support for recommended interventions, and may facilitate the direction of both local and national insulin prescribing safety improvement efforts.
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Affiliation(s)
- A Bain
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S S Hasan
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - S Kavanagh
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Z-U-D Babar
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
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Bain A, Silcock J, Kavanagh S, Quinn G, Fonseca I. Improving the quality of insulin prescribing for people with diabetes being discharged from hospital. BMJ Open Qual 2019; 8:e000655. [PMID: 31523740 PMCID: PMC6711447 DOI: 10.1136/bmjoq-2019-000655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/06/2019] [Accepted: 08/06/2019] [Indexed: 12/27/2022] Open
Abstract
Medication errors involving insulin in hospital are common, and may be particularly problematic at the point of transfer of care. Our aim was to improve the safety of insulin prescribing on discharge from hospital using a continuous improvement methodology involving cycles of iterative change. A multidisciplinary project team formulated locally tailored insulin discharge prescribing guidance. After baseline data collection, three 'plan-do-study-act' cycles were undertaken over a 3-week period (September/October 2018) to introduce the guidelines and improve the quality of discharge prescriptions from one diabetes ward at the hospital. Discharge prescriptions involving insulin from the ward during Monday to Friday of each week were examined, and their adherence to the guidance measured. After the introduction of the guidelines in the form of a poster, and later a checklist, the adherence to guidelines rose from an average of 50% to 99%. Qualitative data suggested that although it took pharmacists slightly longer to clinically verify discharge prescriptions, the interventions resulted in a clear and helpful reminder to help improve discharge quality for the benefit of patient safety. This project highlights that small iterative changes made by a multidisciplinary project team can result in improvement of insulin discharge prescription quality. The sustainability and scale of the intervention may be improved by its integration into the electronic prescribing system so that all users may access and refer to the guidance when prescribing insulin for patients at the point of discharge.
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Affiliation(s)
- Amie Bain
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jon Silcock
- School of Pharmacy and Medical Sciences, University of Bradford Faculty of Life Sciences, Bradford, UK
| | - Sallianne Kavanagh
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gemma Quinn
- School of Pharmacy and Medical Sciences, University of Bradford Faculty of Life Sciences, Bradford, UK
| | - Ines Fonseca
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Bain A, Hasan SS, Babar ZUD. Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review. Diabet Med 2019; 36:948-960. [PMID: 31050037 DOI: 10.1111/dme.13982] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2019] [Indexed: 12/12/2022]
Abstract
AIM To conduct a systematic review of literature to identify interventions that are effective in improving insulin prescribing for people with diabetes in the hospital setting. METHODS Computerized bibliographic databases were searched for studies published in English that described the effectiveness of interventions to improve insulin prescribing within the hospital setting. Studies were eligible for inclusion if they reported data that compared insulin prescribing practice after an intervention or compared with a control group. Studies were not excluded on the basis of publication date, geographical location or risk of bias assessment. RESULTS We identified 35 studies for inclusion in the review, including two cluster randomized controlled trials, two cohort studies, and 31 uncontrolled before-after studies. Studies reported a variety of interventions that aimed to increase insulin prescribing accuracy or completeness or decrease the use of discouraged subcutaneous sliding scale insulin regimens. Differences in definition of insulin prescribing error, terminology and common practice based on geographical location was evident, and quality issues with respect to study design and reporting somewhat limited the interpretation of conclusions. CONCLUSIONS Implementing strategies that are sensitive to local context and designed to increase adherence to insulin prescribing guidelines are associated with a reduction in prescribing errors. Future implementation should build on effective approaches including multifaceted interventions involving multiple stakeholders at various institutional levels. Future studies in insulin prescribing errors would benefit from the use of standardized approaches, terminology and outcome measures to enable greater comparison.
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Affiliation(s)
- A Bain
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S S Hasan
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
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Smego A, Lawson S, Courter JD, Warden D, Corathers S. Decreasing the Time to Insulin Administration for Hospitalized Patients With Cystic Fibrosis-Related Diabetes. Hosp Pediatr 2018; 8:288-292. [PMID: 29691278 DOI: 10.1542/hpeds.2017-0199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Children with cystic fibrosis-related diabetes (CFRD) represent a commonly hospitalized pediatric population whose members require insulin for blood glucose (BG) control. The aim of this quality improvement initiative was to increase the proportion of hospitalized patients with CFRD receiving insulin within 30 minutes of a BG check while decreasing severe hypo- and hyperglycemia episodes. METHODS Quality improvement methodology (gathering a team of stakeholders, identifying metrics, implementing iterative plan-do-study-act cycles and analysis of data over time) was applied in the setting of a cystic fibrosis unit in a tertiary care children's hospital. The percentage of patients with CFRD who received rapid-acting insulin within 30 minutes of a BG check and the rates of hypoglycemia (BG <70 mg/dL) and hyperglycemia (BG >200 mg/dL) were measured. Improvement interventions were focused on efficient communication among patients, nurses and providers; refining carbohydrate calculation; and sharing expectations with patients and caregivers. RESULTS The proportion of rapid-acting insulin doses given within 30 minutes increased from a baseline mean 40% to a sustained mean of 78%. During active improvement interventions, success rates of 100% were achieved. Hyperglycemic events (BG >200 mg/dL) decreased from 125 events to 85 events per 100 rapid-acting insulin days. Hypoglycemic events (BG <70 mg/dL) remained low at <5 events per 100 rapid-acting insulin days. CONCLUSIONS Systematic implementation of low-cost interventions successfully resulted in measurable improvement in timely rapid-acting insulin administration for hospitalized patients with CFRD and lower rates of severe hypo- and hyperglycemia on the unit. Future efforts will be directed to increase the reliability of interventions to maintain optimal performance and outcomes.
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Affiliation(s)
| | | | | | - Deborah Warden
- Patient Services, Cystic Fibrosis/Complex Pulmonary Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Wells S, Rafter N, Eggleton K, Turner C, Huang Y, Bullen C. Using run charts for cardiovascular disease risk assessments in general practice. J Prim Health Care 2016; 8:172-8. [PMID: 27477560 DOI: 10.1071/hc15030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Run charts are quality improvement tools. AIM To investigate the feasibility and acceptability of run charts displaying weekly cardiovascular disease (CVD) risk assessments in general practice and assess their impact on CVD risk assessments. METHODS A controlled non-randomised observational study in nine practices using run charts and nine control practices. We measured the weekly proportion of eligible patients with completed CVD risk assessments for 19 weeks before and after run charts were introduced into intervention practices. A random coefficients model determined changes in CVD risk assessment rates (slope) from pre- to post- intervention by aggregating and comparing intervention and control practices' mean slopes. We interviewed staff in intervention practices about their use of run charts. RESULTS Seven intervention practices used their run chart; six consistently plotting weekly data for >12 weeks and positioning charts in a highly visible place. Staff reported that charts were easy to use, a visual reminder for ongoing team efforts, and useful for measuring progress. There were no significant differences between study groups: the mean difference in pre- to post-run chart slope in the intervention group was 0.03% more CVD risk assessments per week; for the control group the mean difference was 0.07%. The between group difference was 0.04% per week (95% CI: -0.26 to 0.35, P = 0.77). DISCUSSION Run charts are feasible in everyday general practice and support team processes. There were no differences in CVD risk assessment between the two groups, likely due to national targets driving performance at the time of the study.
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Affiliation(s)
- Susan Wells
- 1 Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, New Zealand
| | | | - Kyle Eggleton
- 3 Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, New Zealand
| | - Catherine Turner
- 4 Population Health Strategist/Analyst, Northland Primary Health Organisations
| | - Ying Huang
- 1 Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, New Zealand
| | - Chris Bullen
- 5 Director, The National Institute for Health Innovation (NIHI), School of Population Health, University of Auckland, New Zealand
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Khodyakov D, Ridgely MS, Huang C, DeBartolo KO, Sorbero ME, Schneider EC. Project JOINTS: What factors affect bundle adoption in a voluntary quality improvement campaign? BMJ Qual Saf 2014; 24:38-47. [DOI: 10.1136/bmjqs-2014-003169] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Taylor CG, Krimholtz M, Belgrave KC, Hambleton I, George CN, Rayman G. The extensive inpatient burden of diabetes and diabetes-related foot disease in Barbados. Clin Med (Lond) 2014; 14:367-70. [PMID: 25099836 PMCID: PMC4952828 DOI: 10.7861/clinmedicine.14-4-367] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In this study, we evaluated the burden and quality of adult inpatient diabetes care in Barbados. Inpatients were reviewed over 2 days to identify those with diabetes. Data were collected and analysed from identified patients, their notes and management charts using an audit methodology developed in the UK. Inpatient diabetes prevelance was found to be 42.5% (111 of 261 beds audited). Insulin-treated type 2 diabetes affected 41.8% of the patients. Diabetic foot disease accounted for 30% of admissions and 89% of diabetes-related admissions. Of the patients admitted without diabetic foot disease, 13.9% had their feet examined and 2.8% developed foot lesions during their stay. Medication errors were experienced by 41.4% of patients. We recorded the prevalence of inpatient diabetes in the English medical literature (42.5%) and this was significantly driven by diabetic foot disease. Care needs were complex and areas of potential improvement were identified.
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Affiliation(s)
| | | | | | - Ian Hambleton
- Tropical Medicine Research Institute, University of the West Indies, Barbados
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Using Numbers Creates Value for Health Professionals: A Quantitative Study of Pain Management in Palliative Care. PHARMACY 2014. [DOI: 10.3390/pharmacy2030205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Taylor CG, Morris C, Rayman G. An interactive 1-h educational programme for junior doctors, increases their confidence and improves inpatient diabetes care. Diabet Med 2012; 29:1574-8. [PMID: 22507265 DOI: 10.1111/j.1464-5491.2012.03688.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To evaluated whether a 1 hour, interactive, case-based programme could improve the quality of care and juniors' confidence. METHODS We designed an educational programme using a patient's journey from admission to discharge in order to teach avoidance of common errors, while enhancing familiarity with local charts and protocols. The intervention was delivered in four hospitals, to doctors within 4 years of training following graduation. Feedback was received. The quality of care provided and the confidence of juniors' in its provision was evaluated before and after the intervention. RESULTS Of the 242 trainees taught, 205 (85%) provided feedback. The programme was rated 'very' or 'extremely' easy to understand by 94.1%. The format was thought to improve attention and participation, 'quite a lot' or 'extremely' by 94.1% and was 'highly' or 'extremely highly' recommended for other areas of teaching by 93.1%. The mean confidence score increased from 17.6 (SD 4) to 24.9 (SD 2.7) (P < 0.001), with Cronbach α coefficients of 0.81 and 0.86 for the questionnaires before and after the programme. Insulin prescription errors were reduced by 49% (15.4% before and 7.8% after, P < 0.05). CONCLUSION The inpatient diabetes education programme, which is deliverable within 1 h, was liked by juniors, increased their confidence and improved the quality of inpatient diabetes care.
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Affiliation(s)
- C G Taylor
- University of the West Indies, Cave Hill, Barbados
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Abstract
RATIONALE AND AIM Evidence of the benefits of clinical audit to patient care is limited, despite its longevity. Additionally, numerous attitudinal, professional and organizational barriers impede its effectiveness. Yet, audit remains a favoured quality improvement (QI) policy lever. Growing interest in QI techniques suggest it is timely to re-examine audit. Clinical audit advisors assist health care teams, so hold unique cross-cutting perspectives on the strategic and practical application of audit in NHS organizations. We aimed to explore their views and experiences of their role in supporting health care teams in the audit process. METHOD Qualitative study using semi-structured and focus group interviews. Participants were purposively sampled (n = 21) across health sectors in two large Scottish NHS Boards. Interviews were audio-taped, transcribed and a thematic analysis performed. RESULTS Work pressure and lack of protected time were cited as audit barriers, but these hide other reasons for non-engagement. Different professions experience varying opportunities to participate. Doctors have more opportunities and may dominate or frustrate the process. Audit is perceived as a time-consuming, additional chore and a managerially driven exercise with no associated professional rewards. Management failure to support and resource changes fuels low motivation and disillusionment. Audit is regarded as a 'political' tool stifled by inter-professional differences and contextual constraints. CONCLUSIONS The findings echo previous studies. We found limited evidence that audit as presently defined and used is meeting policy makers' aspirations. The quality and safety improvement focus is shifting towards 'alternative' systems-based QI methods, but research to suggest that these will be any more impactful is also lacking. Additionally, identified professional, educational and organizational barriers still need to be overcome. A debate on how best to overcome the limitations of audit and its place alongside other approaches to QI is necessary.
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Affiliation(s)
- Paul Bowie
- NHS Education for Scotland, Glasgow, Scotland, UK.
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Svoronos T, Mate KS. Evaluating large-scale health programmes at a district level in resource-limited countries. Bull World Health Organ 2011; 89:831-7. [PMID: 22084529 DOI: 10.2471/blt.11.088138] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 06/27/2011] [Accepted: 07/03/2011] [Indexed: 11/27/2022] Open
Abstract
Recent experience in evaluating large-scale global health programmes has highlighted the need to consider contextual differences between sites implementing the same intervention. Traditional randomized controlled trials are ill-suited for this purpose, as they are designed to identify whether an intervention works, not how, when and why it works. In this paper we review several evaluation designs that attempt to account for contextual factors that contribute to intervention effectiveness. Using these designs as a base, we propose a set of principles that may help to capture information on context. Finally, we propose a tool, called a driver diagram, traditionally used in implementation that would allow evaluators to systematically monitor changing dynamics in project implementation and identify contextual variation across sites. We describe an implementation-related example from South Africa to underline the strengths of the tool. If used across multiple sites and multiple projects, the resulting driver diagrams could be pooled together to form a generalized theory for how, when and why a widely-used intervention works. Mechanisms similar to the driver diagram are urgently needed to complement existing evaluations of large-scale implementation efforts.
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Affiliation(s)
- Theodore Svoronos
- Institute for Healthcare Improvement, 20 University Road, Cambridge, MA 02138, United States of America.
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Cheung NW, Cinnadaio N, O'Neill A, Koller L, Pratt HL, Zingle C, Chipps DR. Implementation of a dedicated hospital subcutaneous insulin prescription chart: effect on glycaemic control. Diabetes Res Clin Pract 2011; 92:337-41. [PMID: 21411174 DOI: 10.1016/j.diabres.2011.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 01/19/2011] [Accepted: 02/14/2011] [Indexed: 01/08/2023]
Abstract
A dedicated subcutaneous insulin prescription chart incorporating glucose monitoring results, forced functions, and management guidelines was introduced to facilitate better hospital diabetes control. Point of care capillary blood glucose monitoring charts for 99 people with diabetes from the period before the introduction of the new chart, and 106 after its introduction were reviewed. A total of 12,649 blood glucose levels (BGLs) were collected for glucometric analysis. Following the introduction of the chart, there was an increase in the number of BGLs performed daily from 4.5 ± 1.2 to 4.9 ± 1.3 (p = 0.05). There was an increase in the proportion of BGLs within the ideal range of 4-9.9 mmol/L (51.8% vs. 54.1%, p = 0.01). There was a reduction in hypoglycaemic events (proportion of BGLs <4 mmol/L in the whole population decreased from 5.2% to 3.4% (p < 0.001), proportion of BGLs <4 mmol/L for each patient decreased from 5.6 ± 9.2% to 2.9 ± 5.4% (p = 0.01), proportion of days where patient had a BGL <4 mmol/L decreased from 17.6 ± 22.6% to 11.4 ± 18.8% (p = 0.03)), despite an increase in the use of supplemental insulin (14.2 ± 35.7 vs. 29.4 ± 51.4 u nits/patient, p = 0.02). We conclude that the use of a dedicated hospital subcutaneous insulin prescription chart can reduce hypoglycaemia and improve some measures of glycaemic control.
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Affiliation(s)
- N W Cheung
- Department of Diabetes & Endocrinology, Westmead Hospital, Westmead, NSW 2145, Australia.
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Powell A, Rushmer R, Davies H. Effective quality improvement: some necessary conditions. ACTA ACUST UNITED AC 2009. [DOI: 10.12968/bjhc.2009.15.2.39168] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Alison Powell
- Social Dimensions of Health Institute, Universities of Dundee and St Andrews
| | - Rosemary Rushmer
- Health Services Research, Social Dimensions of Health Institute, Universities of Dundee and St Andrews
| | - Huw Davies
- Social Dimensions of Health Institute, Universities of Dundee and St Andrews
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