PLYMOUTH MEETING, PA—Insulin has consistently been declared a high-alert medication due to the risks associated with its prescribing and dosing. When a nutrition order for a patient is modified, the patient’s insulin regimen may inadvertently remain unreviewed or unchanged. ECRI Institute Patient Safety Organization (PSO) has seen both events and research requests pertaining to this issue.
“Because diabetic and non-diabetic patients receiving nutritional therapy and insulin are often managed by more than one practitioner, facilities need to implement a standardized process to ensure coordinated care,” states Karen P. Zimmer, MD, MPH, FAAP, medical director, ECRI Institute PSO. “Yet when we further explored this topic, there was minimal literature that discussed best practices and among the hospitals we approached, there was no consensus on how to best go about this. The analysis of aggregated reports continues to reveal gaps that we need to address.”
ECRI Institute PSO’s recently released Patient Safety E-lert, “It’s More Than Counting Carbs, It’s Communication and Coordination: Insulin Administration and Nutritional Therapy,” highlights this patient safety issue involving patients who are receiving enteral or total parenteral nutrition and insulin. The issue came to light when ECRI Institute PSO analyzed reports submitted by participating healthcare providers. As part of its mission to research the best approaches to improving patient care, ECRI Institute is sharing this special E-lert with the healthcare community.
“Reports submitted to Patient Safety Organizations can surface less-known or undetected risks, like those highlighted in this report,” states Barbara Rebold, RN, MS, CPHQ, director of operations, ECRI Institute PSO. “We want to share the potential risk we are seeing in our PSO reports and recommend ways to prevent or mitigate that risk.”
For questions about this topic, or for information about ECRI Institute PSO, contact ECRI Institute by telephone at (610) 825-6000, ext. 5558; by e-mail at email@example.com; by fax at (610) 834-1275, or by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA. To sign up for the PSO Monthly Brief, a free eNewsletter comprised of a brief article each month to help keep readers informed about Patient Safety Organizations, go to www.ecri.org/psobrief.
About ECRI Institute
For nearly 45 years, ECRI Institute’s work in patient safety, adverse event reporting and analysis, and development of recommendations has improved patient care at hospitals and other providers around the world. The ECRI Institute Patient Safety Organization is a component of ECRI Institute, a nonprofit 501(c)(3) organization dedicated to improving the safety, quality, and cost-effectiveness of patient care. ECRI Institute has a long history of investigating adverse events and publishing authoritative risk reduction strategies. ECRI Institute is designated as an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute developed and implements the Pennsylvania Patient Safety Reporting System, a mandatory error and near-miss reporting program for Pennsylvania hospitals and other healthcare facilities, under contract to the Pennsylvania Patient Safety Authority, winner of the 2006 John M. Eisenberg Award. For more information, visit www.ecri.org. Find ECRI Institute on Facebook (www.facebook.com/ECRIInstitute) and Twitter (www.twitter.com/ECRI_Institute).
For more information, contact:
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