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Cutting the Pediatric Insulin Error Rate

Kuznar, Wayne

Editor(s): Pfeifer, Gail M. MA, RN

Author Information
AJN, American Journal of Nursing: November 2010 - Volume 110 - Issue 11 - p 17
doi: 10.1097/01.NAJ.0000390507.22899.96
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An online learning module completed by pediatric nurses cut insulin administration errors by more than 80%, according to investigators at the University of California, San Francisco (UCSF), Medical Center. All of the hospital's 283 pediatric nurses underwent training with the three-part module. Before implementation of the training, the mean error rate was 5.2 errors per patient; after implementation, it was 0.86 errors per patient. The effect of the training on insulin administration errors was maintained over at least six months.

In addition to being recognized as a high-risk medication by the Joint Commission, insulin is also used infrequently in the pediatric inpatient population (one or two patients per week at UCSF), which increases the risk of administration errors, said Mary M. Sullivan, the study's lead author and a diabetes clinical nurse specialist at UCSF. "It's difficult to maintain competency from one month to the next because we don't see these patients very often," she said. "What confounds the issue is the use of diluted insulin in pediatric patients. Even though we standardize our concentration, nurses go looking for U10 syringes, and they don't exist. We want to avoid creativity." The need for the program had been made evident by incident reports and audits, she added.

The nurses were given one month to complete the education module, part of which entails correctly answering 15 questions about interpreting insulin orders, determining correct insulin dosing, and identifying nursing actions. Immediate feedback is provided; when a nurse gives an incorrect answer, she or he is immediately shown why the answer is incorrect and must answer the question again. (The module can be found at

"The challenges are to engage the nursing staff and all of the key stakeholders: hospital administration, nursing education, the respective physician groups, and the staff nurses," said Sullivan. "What worked at our institution was to identify "unit champions," the key staff nurses who engaged in the process and encouraged their fellow staff nurses to do the module."

If the module couldn't be completed during working hours, nurses were paid to do it on their own time.—Wayne Kuznar

Sullivan MM, et al. Diabetes Care 2010;33(8):1744-6.
    © 2010 Lippincott Williams & Wilkins, Inc.