Concentrated insulin is five times stronger than standard insulin, but because the names of the two are similar and both are typically administered with a standard insulin syringe, miscommunication between admitted diabetic patients and hospital staff is common. If a patient administers his concentrated insulin by filling a standard syringe to the 50 units line, for example, he might tell his physician that he’s taking 50 units a day. If the physician thinks the patient means 50 units of standard insulin, the patient could receive a severe underdose.
Cleveland Clinic tackled this issue by implementing decision support tools in Epic. The system prompts physicians and pharmacists to confirm that they’re ordering the right type of insulin and to document the type of syringe that patients use to administer their insulin. When physicians sign orders for concentrated insulin, an order for an endocrinology consult is automatically placed for the patient to prevent adverse reactions from this higher-risk dose. Within five months of implementing these tools, Cleveland Clinic reduced their wrong-dose errors by 50%.
This program is available to new members of the Epic community in the Foundation System. Epic community members can download this program here and have Epic staff install it as part of Epic’s Services. If you’re interested, please contact firstname.lastname@example.org.