|
Domain 1: Risk behaviors related to documentation record failures in the healthcare environment
|
| Use of inappropriate abbreviations and symbols in insulin prescriptions, such as "U" and "UI" instead of the word "units," which may lead to improper dose interpretation. |
68 (79) |
34 (85) |
34 (74) |
0.207 |
| In-use insulin vials without a label indicating the opening date, posing the risk of using insulin beyond its expiration date |
48 (56) |
15 (38) |
33 (72) |
0.001 |
| The professional administered the prescribed insulin without checking the prescription, resulting in re-administration by another professional, which caused hypoglycemia in the patient |
18 (21) |
5 (13) |
13 (28) |
0.073 |
| Failure to suspend prandial insulin (rapid or ultra-rapid action) in patients on a zero diet (e.g., Administration of regular insulin in a patient on a zero diet for exams, resulting in hypoglycemia). |
36 (42) |
17 (43) |
19 (41) |
0.911 |
|
Domain 2: Use of inappropriate instruments for insulin administration, leading to risks in calibration precision and errors in the administered dose.
|
| Use of syringes calibrated in milliliters (ml) instead of international units. |
28 (33) |
9 (23) |
19 (41) |
0,063 |
| Use of syringes with detached needles. |
45 (52) |
17 (43) |
28 (61) |
0.089 |
| Reuse of insulin needles and syringes. |
57 (66) |
26 (65) |
31 (67) |
0.815 |
| Use of the content of a prefilled pen in another device (syringe). Example: Due to a lack of knowledge about the different presentations and concentrations of insulin, a syringe was used to aspirate Toujeo insulin (glargine U300) from a prefilled pen, resulting in an overdose and late hypoglycemia. |
13 (15) |
4 (10) |
9 (20) |
0.217 |
|
Domain 3: Failures in the insulin storage process.
|
| Storage of insulins in inappropriate locations, such as on the refrigerator door, in the freezer, or outside the refrigerator in areas with high temperatures (above 30°C) or direct sunlight exposure. |
64 (74) |
30 (75) |
34 (74) |
0.908 |
| Storage of insulins and heparins near refrigerator sections. |
19 (22) |
4 (10) |
15 (33) |
0.012 |
| Storage of insulins and vaccines in the same refrigerator section. |
15 (17) |
6 (15) |
9 (20) |
0.578 |
|
Domain 4: Failures in the insulin preparation process.
|
| Failure to homogenize suspension insulins (e.g., NPH) before aspiration. |
50 (58) |
24 (60) |
26 (57) |
0.744 |
| Combining human insulins in the same syringe without respecting the proper aspiration order (correct order: regular followed by NPH). |
43 (50) |
19 (48) |
24 (52) |
0.665 |
| Combined use in the same administration device of basal insulin analogs (glargine-100, detemir, degludec, glargine-300) with regular insulin or prandial analogs (aspart, glulisine, lispro, or fiasp). |
7 (8) |
3 (7.5) |
4 (8.7) |
>0.999 |
|
Domain 5: Failures in the insulin administration process.
|
| Failure to rotate insulin injection sites. |
73 (84) |
33 (83) |
40 (87) |
0.565 |
| Administration of insulin with large needles (≥ 8mm), using improper angulation (90°) or without creating a skinfold, increasing the risk of intramuscular injection. |
38 (44) |
12 (30) |
26 (57) |
0.014 |
| Confusion between different types and doses of insulin prescribed at the same time, leading to administration errors (e.g., A patient started a regimen consisting of 35 units of insulin glargine (long-acting) and 6 units of insulin aspart (rapid-acting). Accidentally, a healthcare professional administered 35 units of aspart, resulting in hypoglycemia). |
37 (43) |
16 (40) |
21 (46) |
0.597 |
| Inappropriate timing between insulin administration and meals (e.g., regular insulin was prescribed 30 minutes before lunch but was administered 1 hour prior, resulting in hypoglycemia). |
63 (73) |
32 (80) |
31 (67) |
0.188 |
|
Domain 6: Failures in the disposal of sharps related to diabetes treatment.
|
| Leaving the pen needle attached after use, increasing the risk of sharps-related accidents, as well as the possibility of air entering the pen cartridge and insulin leakage. |
42 (49) |
18 (45) |
24 (52) |
0.507 |
| Disposal of sharps related to diabetes treatment in inappropriate locations (e.g., disposal of needles, syringes, or lancets in regular trash). |
62 (72) |
31 (78) |
31 (67) |
0.297 |
FAILURES IN THE PRACTICES OF PREPARATION AND ADMINISTRATION OF INSULINS: SITUATIONAL DIAGNOSIS FOR PATIENT SAFETY