FALLAS EN LAS PRÁCTICAS DE PREPARACIÓN Y ADMINISTRACIÓN DE INSULINAS: DIAGNÓSTICO DE SITUACIÓN PARA SEGURIDAD DEL PACIENTE

Moreira, Tatiana Rebouças; Silva, Lucilane Maria Sales da; Oliveira, Adriana Catarina de Souza; Carvalho, Rhanna Emanuela Fontenele Lima de

doi:10.1590/1980-265X-TCE-2024-0217en

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Original Article • Texto contexto - enferm. 34 • 2025 • https://doi.org/10.1590/1980-265X-TCE-2024-0217en linkcopiar

FALLAS EN LAS PRÁCTICAS DE PREPARACIÓN Y ADMINISTRACIÓN DE INSULINAS: DIAGNÓSTICO DE SITUACIÓN PARA SEGURIDAD DEL PACIENTE

Autoría SCIMAGO INSTITUTIONS RANKINGS

Objetivo: identificar las fallas relacionadas con las prácticas de preparación y administración de insulina en ambientes asistenciales, desde la perspectiva comparativa de profesionales de salud y expertos.

Método: estudio observacional transversal realizado con 86 profesionales de salud, entre auxiliares de un hospital de Fortaleza-Ceará y expertos en el área, entre agosto de 2023 y abril de 2024. Se utilizó un instrumento con 20 ítems de verificación múltiple, divididos en seis dominios, para identificar los principales errores y eventos adversos relacionados con la seguridad del paciente resultantes de las actividades de preparación y administración de insulina en la práctica asistencial.

Resultados: las inconsistencias más frecuentemente señaladas por los profesionales sanitarios fueron: no rotar los lugares de aplicación de la insulina; uso de abreviaturas y símbolos inapropiados en la prescripción de insulinas; viales en uso sin registro (etiqueta) de la fecha de apertura; envasado inadecuado de las insulinas; intervalo incorrecto entre la administración de insulina y una comida; y eliminación de los objetos punzantes relacionados con el tratamiento en un lugar inapropiado. La identificación de los aspectos «Viales de insulina en uso sin registro (etiqueta) de la fecha de apertura», «Almacenamiento de insulinas y heparinas en sectores próximos a la heladera» y «Administración de insulina con agujas grandes, realizando una angulación inadecuada o sin hacer el pliegue subcutáneo» fue significativamente mayor entre los profesionales expertos.

Conclusión: estos hallazgos son importantes por ser indicadores de la seguridad del paciente, contribuyendo a la replanificación de las acciones dirigidas a mejorar la calidad de la atención prestada a las personas con diabetes.

DESCRIPTORES:
Personal sanitario; Diabetes mellitus; Insulina; Buenas prácticas de manipulación; Seguridad del paciente

Requirements	Characteristics
Possess skills/knowledge acquired through experience.	Have professional experience providing care to people with diabetes or working in units that receive patients with diabetes. Have teaching experience in the field of diabetes. Have experience conducting individual and group activities in the field of diabetes. Participate in a health research project focused on diabetes.
Possess specialized skills/knowledge that make the professional an authority on the subject.	Have been an invited speaker at a national or international scientific event in the field of diabetes. Have supervised academic works at the undergraduate or graduate level in the field of diabetes. Possess specialization/residency in the field of diabetes. Hold a master’s or doctoral degree with a dissertation or thesis in the field of diabetes.
Demonstrate special expertise in a specific type of study.	Have experience in developing research in the diabetes field and/or validation of technologies and instruments. Be an author of scientific article(s) on topics related to diabetes and/or validation of technologies and instruments, published in journals classified by CAPES. Participate on evaluation boards for graduate-level academic works (Master’s and Doctorate) with methodological research in any field.
Pass a specific test to identify qualified judges.	Be a professional certified by the Brazilian Diabetes Society and/or other organizations focused on diabetes.
Receive high classification attributed by an authority.	Be recognized by a well-known scientific institution with an honor/mention as an authority in the diabetes field. Have award-winning papers at national or international scientific events, with content related to diabetes and/or validation of technologies and instruments.

Characterization of frontline healthcare professionals and experts.	Total (%)	Assistance n=40¹	Expert n=46¹	p-value²
Age	33.5 ± 8	28 ± 4	38 ± 12	<0001
Years of professional experience	8.9 ± 6.8	3.5 ± 3.2	13.7 ± 10.3	<0001
Years of experience in the field.	5.7 ± 4.9	2.1 ± 2.9	8.8 ± 6.9	<0001
Gender				0.31
Female	74 (86)	32 (37)	42 (49)
Male	12 (14)	8 (9)	4 (5)
Rating				0.6447
Nursing	45 (52)	19 (47.5)	26 (57)
Nutrition	15 (17)	8 (20)	7 (15)
Physiotherapy	10 (12)	4 (10)	6 (13)
Medicine	15 (17)	9 (22.5)	6 (13)
Psychology	1 (2)	0	1 (2)
Degree
Rating	15 (17.4)	15 (37.5)	0	<0001
Specialization	41 (47.6)	24 (60)	17 (37)
Master's degree	30 (34.8)	5 (12.5)	25 (54)
PhD	11 (12.7)	0	11 (24)

Errors and adverse events	Total n (%)	Assistance n =40	Expert n =46	p-value ¹
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

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