Medication errors are a primary source of patient injury that plague our healthcare system. According to the Physicians Insurers Association of America, in 2008, 334 claims closed with a medication error. Medication errors related to the treatment of diabetes are more common than one would like to think. This is in part due to the many facets involved in diabetes treatment from insulin administration to blood sugar monitoring both at home and in the hospital setting.
A central problem with our health care system is our ability (or lack of ability) to handle medical information. Electronic medical records are becoming more the norm which makes transfer of care from home to hospital more seamless. In the treatment of the patient with diabetes, teamwork is essential. Nursing ratios should be higher for patients with diabetes in the hospital setting. There is an implied need for frequent glucose monitoring, dietary planning, and monitoring for infection, just to name a few. There is no room for egos and turf wars when specialists and hospitalists need to work side by side for the best interest of the patient.
[Physician Assistant Profession and the utilization as an Expert Witnesss]
Insulin is one of the most dangerous drugs used in the hospital setting, because when a mistake is made severe injury or death can occur within minutes. There need to be safety checks and sign-offs in place every step of the way so that an insulin order does not get misinterpreted. Strict protocols should be adhered to with regard to units of insulin not being mistaken for ml. Insulin syringes should always be used and insulin pens must never be shared among patients.
A large majority of medication errors are a result of employees who are not licensed and not adequately proctored or trained. Staff training and retraining is a basic tenant of risk management. Medical staff must always keep in mind the 5 R’s; Right patient, Right medication, Right route, Right dosage, Right time.
Without written protocols for patients with diabetes there is huge risk of liability and more importantly, patient harm. A Certified Diabetes Educator should be on call at all times to review orders and make recommendations to the team to improve patient care. We don’t want to put up the traffic light because there have been too many accidents. My goal as a Diabetes Educator is to help keep patients with diabetes safer in the Health Care Setting.
Written by: Registered Pharmacist and Diabetes Educator Expert Witness No. 3591
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