Insulin Administration: Translating Evidence into Practice

Researchable Problem

The process of identifying a researchable problem can significantly impact the following steps of conducting a study. The feasibility of the final question and its elements can either simplify or complicate the search of information and the outcomes of research. Thus, prior to formulating the main research problem, it is vital not only to describe the sphere of interest and its possible issues but also analyze possible frameworks which can be used for developing a topic which produces measurable results.

Area of Interest

Clinical practice has many areas where one’s errors can negatively impact patient outcomes and their overall health. For example, the high rate of medication administration errors (MAEs) is an issue that has a direct impact on an individual’s health. MAEs may include incorrect dosage and missed or repeated administration, which may lead to such negative outcomes as an overdose. According to Keers, Williams, Cooke, Walsh, and Ashcroft (2014), a major part of all adverse events leading to patient harm is connected to medication. The rate of MAEs is also high in hospitals, contributing to almost 20 percent of all possible opportunities for error. Thus, the problem of medication administration has to be analyzed in more detail. Insulin administration errors, while considered less dangerous as opposed to intravenous injections, can still significantly impact patients’ health.

Problem

Medication errors that involve nurses administering insulin to a patient are common. According to Nguyen, Nguyen, Haaijer-Ruskamp, and Taxis (2014), the error rate for insulin administration at the investigated hospitals reached almost 30 percent. Currently, the number of patients treated with insulin continues to grow, which makes the problem more pressing than before (Geller et al., 2014). Thus, some ways of error prevention have to be considered. One of the potential interventions is a double-checking process (Alsulami, Choonara, & Conroy, 2014). It is standard practice in many healthcare organizations, although it is unclear how significantly its implementation contributes to the decreasing error rates (Hewitt, Chreim, & Forster, 2016). This procedure may have its benefits and drawbacks and should be investigated further to establish if it helps to reduce the occurrence of MAEs related to insulin.

Significance

The problem of insulin administration errors needs to be addressed because of the growing prevalence of patients with diabetes who need to be treated with insulin in a hospital setting. The number of individuals who require insulin injections or other types of administration continues to grow (Geller et al., 2014). The rates of errors may also increase due to the rising workload of nurses and the admission of patients lacking education about self-administration (Nguyen et al., 2014). Incorrect use of insulin may lead to patients developing hypoglycemia, characterized by sweating, weakness, and loss of consciousness (Geller et al., 2014). Some more severe consequences include seizures and even death. Thus, it is vital to address the problem of administration errors and find a way to decrease their rate.

Developing Research Questions

What is the rate of insulin administration errors in a chosen hospital?

This question, while introducing a possible area of research, does not lead to the introduction of any solutions to the problem of MAEs. Thus, it is not feasible for this discussion, although it relates to the area of interest for this study.

What causes errors in medication administration in a hospital setting?

This example encourages a discussion about common reasons behind mistakes related to medication administration. It corresponds with the topic of interest and allows one to see which concerns need to be addressed for future improvements. However, it does not present a strategy that can be evaluated for implementation. This question should be eliminated because it is not a feasible foundation for a PICOT question, although it can be researched in more detail.

What differences exist between various interventions for reducing MAEs?

Here, the possibility of introducing solutions for the discussed problem is present. However, the scope of research does not allow developing a study that tests a specific intervention and produces measurable and usable results. Thus, this question cannot be reformulated to become a useful PICOT topic.

What are the reasons for using interventions such as double checking for MAEs?

This question relates to the area of interest and connects it to a possible intervention strategy. Nevertheless, its focus does not provide any measurable outcomes, which could be used for further assessment and future improvements. A study by Raban and Westbrook (2014), for instance, shows that studies with no measurable outcomes should be used in practice with caution. This question indicates that double-checking may be used for reducing errors, but it does not ask how advantageous this procedure may be.

How effective is the implementation of a double-checking method for reducing errors in the process of insulin administration?

The effectiveness of an intervention is a topic that can be reformulated into a PICOT question. This example has all elements for choosing it as a possible research problem because it creates a situation to measurable outcomes and the possibility for an assessment of future options.

PICOT Question

Based on the discussed research problem and the chosen focus, a PICOT question can be developed.

In the process of insulin administration, does the implementation of a dual insulin check by two nurses, as opposed to no double checking, decrease the rate of medication-related errors per year?

  • P – Problem: The process of insulin administration. This problem corresponds to the area of interest.
  • I – Intervention: Double checking by two nurses. Here, one intervention is suggested to see whether it can be valid for practice or not.
  • C – Comparison: No double checking. The comparison with another intervention could complicate the process of measuring the change. On the other hand, contrasting a new strategy with an absence of intervention can show the changes that it may bring.
  • O – Outcome: Decreased rate of medication-relate errors. The desired outcome is the lowered number of errors that nurses make while administering insulin to patients.
  • T – Timeframe: One year. Annual results can be represented in a report and shown to the administration in order to create a new policy for further implementation.

Conclusion

The issue of medication errors during insulin administration is a topic that can be researched from various angles. Nevertheless, an approach that focuses on improving quality of care seems to be the most crucial one, as it can produce positive results for patient safety – one of the most critical aspects of health care. Thus, a PICOT question concerning an introduction of a possible intervention into the practice was developed. Finally, keywords pertinent to the topic were selected

Lirerature Review

The topic of medication administration errors (MAEs) is widely researched in the sphere of healthcare. It has many smaller subtopics based on the type of drugs and possible interventions to reduce the number of mistakes. The information about this research problem may be found in various scholarly resources. The importance of this literature review lies in locating articles that show gaps in knowledge and present new areas for future research in the sphere of MAEs and prevention strategies (Polit & Beck, 2017). This review investigates five articles discussing MAEs, insulin administration, and double checking.

Review

First of all, it may be necessary to research current data regarding the rate of MAEs. Nguyen, Nguyen, Haaijer-Ruskamp, and Taxis (2014) offer some estimates related to MAEs, especially insulin administration errors. According to the authors, these types of mistakes are widespread in clinical settings and may lead to adverse patient outcomes. The study investigated two hospitals and found that error rates were rather high – almost 30% (Nguyen et al., 2014). Moreover, the research also revealed that most of these mistakes led or could have led to severe outcomes. Multiple types of errors were discussed in the study, including the time of the administration, the utilized technique, and the procedure’s omission. The authors concluded that interventions needed to focus on nurses’ education.

When discussing insulin administration, it is important to note that they are considered high-alert medications. Wang et al. (2015) presented a study that offered a trend analysis of possible intervention techniques dealing with MAEs. According to the authors, double checking was mentioned as a required procedure for such drugs’ administration. Nonetheless, it should be noted that the study was not focused on this strategy alone, employing a complex system of educational and optimization initiatives instead. Therefore, the use of double checking was not flashed out in the study, but its connection to insulin administration was established. The researchers concluded that quality improvements could be achieved with accredited frameworks.

The research on using double checking presents different results of its success. For example, Athanasakis (2015) conducted an evidence review which included multiple studies comparing single and double checking. The author also explored the concept of double checking and the inconsistency of its definition. It was found that there were many drawbacks to using the system of double checks, including nurses’ reliance on others to detect possible mistakes, misunderstanding of guidelines leading to conflicts, and the inability to implement this strategy in understaffed settings. However, such benefits as patient safety, nurses’ critical thinking, and collaboration were found as well. As a result, the author concluded that while double checking was regarded as a standard procedure in many hospitals, the evidence about its impact on the rate of MAEs remained inconclusive.

The adherence to double checking can play a significant role in the success of the intervention. Alsulami, Choonara, and Conroy (2014) investigated the level to which nurses followed the hospital’s guidelines about the procedure. They found that only 30% of all administration procedures were double checked by nurses (Alsulami et al., 2014, p. 1404). Although in this particular example the errors were established as causing minimal or no harm to patients, such a low rate of compliance can be significant for future research. Notably, the study by Nguyen et al. (2014) related to insulin administration showed different results, stating that all mistakes could potentially cause harm. Similarly to the analysis mentioned above, Alsulami et al. (2014) found that dosing was one of the most frequent problems. However, the rate of medication errors was significantly lower than that in the study by Nguyen et al. (2014). Such an inconsistency may be explained by the difference in settings and the hospitals’ types.

Low rates of adherence may be connected to nurses’ opinions about double checking and its effectiveness. For instance, Schwappach, Pfeiffer, and Taxis (2016) gathered and analyzed oncology nurses’ views on this procedure. Though this survey, they found that double checking was used in the majority of settings and was generally viewed as positive and appropriate for one’s clinical practice. Moreover, nurses highlighted the useful nature of joint checks as opposed to independent checks by multiple professionals. However, double checking was regarded as an essential procedure by nurses overall. This and the previously discussed studies reveal a difference in nurses’ views on the double checking procedure. Also, it shows that the rate of adherence to this practice may significantly affect its success.

Conclusion

Overall, the sphere of MAEs as a whole is studied by scholars from many sides, although insulin injections take up only a small part of this research. Moreover, although double checking is regarded as an essential practice in many hospitals, its impact on the rate of MAEs is not well-researched, leaving many possibilities for future investigations. The combination of double checks and insulin administration-related errors presents a topic that has to be researched further to acquire more knowledge and develop an effective intervention. Currently, available evidence shows that mistakes related to insulin administrations are widespread and harmful, and their monitoring and mitigation is necessary to improve patient safety. The favorable view of double checking by nurses and organizations can be taken as a foundation for a change proposal.

Translating Evidence into Practice

The research on medication administration errors (MAEs) proposes various strategies to decrease their rate. The choice of the best intervention and its introduction has to be supported by recent and reliable findings to achieve good results and favor sound methods. Thus, an evidence-based practice (EBP) approach has to be implemented to translate other studies’ results into reality (Polit & Beck, 2017). The issue of MAEs, especially insulin administration, is often connected to such concerns as nurses’ lack of attention (Wang et al., 2015). To deal with these problems, studies suggest a project that is based on double checking, in which two nurses confirm all medication administration-related processes. This strategy reduces the rate of MAEs and promotes employees’ collaboration, although it can be met with resistance to change as it creates a higher workload for nurses and requires more time to complete.

PICOT Question Significance

The PICOT question for this research is as follows, “In the process of insulin administration, does the implementation of a dual insulin check by two nurses, as opposed to no double checking, decrease the rate of medication-related errors per year?” In this case, the proposed intervention lies in introducing a double-checking procedure to a hospital. The significance of this research is supported by the rates of MAEs related to insulin injections. According to Nguyen, Nguyen, Haaijer-Ruskamp, and Taxis (2014), almost 30 percents of all procedures have a mistake in the administration step. These errors also lead to severely and moderately adverse outcomes for patients. These findings show that an intervention has to be devised to prevent similar issues from appearing.

Findings from the Literature Review

The literature review shows that researchers continue to investigate possible strategies for MAEs’ rates decrease. However, the majority of studies mention double checking in one form or the other. The article mentioned above, for instance, suggests this activity as a safety measure along with visual reminders for nurses (Nguyen et al., 2014). Athanasakis (2015) presents a review of data collected from organizations which implemented different medication checking methods. The author finds that checking is crucial to patient safety, and double checking should be highlighted as a procedure that has many benefits. Furthermore, Athanasakis (2015) argues that this initiative empowers nurses because it stresses the fact that they possess enough autonomy and responsibility to review their own performance and that of their peers.

Different types of double-checking are also viewed in some scholarly works. Wang et al. (2015) find that an independent double-check is necessary to ensure that everything is done correctly. Schwappach, Pfeiffer, and Taxis (2016) propose a joint procedure – two nurses check the dose and all patient-related information separately in order to decrease the possibility of MAEs. This approach, as opposed to one nurse checking all data twice, is said to be more effective (Schwappach et al., 2016). Overall, both models are seen as essential for medication administration procedures.

Chosen Nursing Practice

Upon reviewing the scholarly research, the joint type of the double-checking procedure is to be chosen for this study. This nursing practice is described in detail by Schwappach et al. (2016), and its effectiveness seems to be high in the article. Furthermore, it is regarded as more useful than the independent one by nurses who state that it is the most appropriate procedure to reduce the rate of errors (Schwappach et al., 2016). The focus on nurses’ autonomy and collaboration mentioned by Athanasakis (2015) supports this procedure as well because it delegates the responsibility among peers without taking their decision-making authority away. The choice between joint and individual versions of the method is principal to the strategy development because it implies different schedules for nurses.

Positive and Negative Outcomes

The decision to implement joint double-checking can lead to a number of positive outcomes. First of all, the rate of mistakes will decrease as noted by the majority of studies about the procedure (Athanasakis, 2015; Nguyen et al., 2014; Schwappach et al., 2016). Therefore, this will directly impact the quality of care and health outcomes of patients. Nurses may find that their collaboration has a more significant influence on the organization. Their responsibility will increase, making their contributions more valuable than before. As Schwappach et al. (2016) note, nurses agree that dual checking helps prevent the majority of errors from occurring. Additionally, they highlight the importance of independence that this intervention brings.

The failure to utilize this method can negatively affect the organization, its workers, and its patients. First of all, the lack of checks increases the possibility of errors, leading to lower patient safety levels. Moreover, patients’ satisfaction can suffer as a result, bringing the hospital’s ratings down. The use of EBP in healthcare is essential in promoting the most innovative activities (Polit & Beck, 2017). The inability of the clinic to change its current state will hinder the path towards improvement. Nurses’ responsibility for these mistakes may also lead to adverse outcomes, as they will either feel stressed and pressured because of the high MAE’s percentage or express the lack of concern for the issue. Such negative results will affect the hospital as a whole and lower the possibility of implementing other practices in the future.

Dissemination of Evidence and Resistance to Change

To successfully introduce the chosen intervention to the organization’s staff, one has to design steps for the findings’ dissemination. The importance of communication cannot be overstated on this stage. Nurses should be informed about this practice and asked whether they know about its benefits and drawbacks. Then, the significance of the procedure has to be defined with the help of supporting literature. Such factors as nurses’ independence and collaboration, patients’ health, and overall satisfaction should be mentioned as well. Then, one should ask nurses to provide some feedback about the proposed idea to increase collaboration and engage others in the discussion (Polit & Beck, 2017). This step may decrease nurses’ resistance and positively affect their understanding.

Finally, the implementation would start with developing a plan for this particular setting. The schedule has to be reviewed to include the time for nurses’ joint checks. Then, if nurses choose a specific order or a place for such procedures, this data has to be included in the plan. To collect helpful ideas, a survey should be conducted. According to Keough and Tanabe (2011), an effective review of others’ opinions can assist nurses in processes of change. A similar survey also has to be disseminated after the new procedure has been introduced. This will help to monitor progress and ensure that the intervention is working as intended.

Conclusion

The rate of insulin MAEs is hospitals can be reduced with the help of particular interventions. The introduction of joint double checking is one of them. Various authors analyzed this procedure and defined it as a way to decrease errors and promote nurses’ independence. To disseminate the information about it, nurses have to be presented with the most relevant findings. The process of implementation has to include continuous feedback to observe the completion of every step.

Summary

The problem of medication administration errors (MAEs) can be researched by using different approaches. It can be divided into a variety of topics regarding specific medications, types of patients, and approaches to its improvement. In the case of insulin administration, in particular, patient safety angle is crucial because many people have to take this medicine daily for the rest of their lives. Thus, a quality of care outlook on the issue is a valuable subject of research. The PICOT question for such a nursing study can focus on a special intervention and its effectiveness for reducing the rate of errors. It can be formulated as such: “In the process of insulin administration, does the implementation of a dual insulin check by two nurses, as opposed to no double checking, decrease the rate of medication-related errors per year?” Here, the intervention is defined along with its supposed effect on patient safety.

The literature review on the topic of MAEs shows that many scholars continue to analyze possible strategies to decrease the rate of mistakes and educate nurses about safe practices. However, the use of joint double checking is not as researched as other medications. Furthermore, the dual method as a procedure is noted to be one of the most utilized approaches in many facilities, although its results vary from one study to another. Many opportunities for future research can be perceived while analyzing the existing literature. For example, the mentioned above topic can show how useful can a joint check by two nurses be for insulin administration. This procedure can not only help reduce the rate of MAEs but also support nurses’ independence. To introduce this method, nurses have to be presented with recent findings and given the ability to provide feedback about the implementation.

References

Alsulami, Z., Choonara, I., & Conroy, S. (2014). Paediatric nurses’ adherence to the double-checking process during medication administration in a children’s hospital: An observational study. Journal of Advanced Nursing, 70(6), 1404-1413.

Athanasakis, E. (2015). The method of checking medications prior to administration: An evidence review. International Journal of Caring Sciences, 8(3), 801-818.

Geller, A. I., Shehab, N., Lovegrove, M. C., Kegler, S. R., Weidenbach, K. N., Ryan, G. J., & Budnitz, D. S. (2014). National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Internal Medicine, 174(5), 678-686.

Hewitt, T., Chreim, S., & Forster, A. (2016). Double checking: A second look. Journal of Evaluation in Clinical Practice, 22(2), 267-274.

Keers, R. N., Williams, S. D., Cooke, J., Walsh, T., & Ashcroft, D. M. (2014). Impact of interventions designed to reduce medication administration errors in hospitals: A systematic review. Drug Safety, 37(5), 317-332.

Keough, V. A., & Tanabe, P. (2011). Survey research: An effective design for conducting nursing research. Journal of Nursing Regulation, 1(4), 37-44.

Nguyen, H. T., Nguyen, T. D., Haaijer-Ruskamp, F. M., & Taxis, K. (2014). Errors in preparation and administration of insulin in two urban Vietnamese hospitals: An observational study. Nursing Research, 63(1), 68-72.

Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Wolters Kluwer.

Raban, M. Z., & Westbrook, J. I. (2014). Are interventions to reduce interruptions and errors during medication administration effective?: A systematic review. BMJ Quality and Safety, 23(5), 414-421.

Schwappach, D. L. B., Pfeiffer, Y., & Taxis, K. (2016). Medication double-checking procedures in clinical practice: A cross-sectional survey of oncology nurses’ experiences. BMJ Open, 6(6), e011394.

Wang, H. F., Jin, J. F., Feng, X. Q., Huang, X., Zhu, L. L., Zhao, X. Y., & Zhou, Q. (2015). Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: A trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era. Therapeutics and Clinical Risk Management, 11, 393-406.