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Improving Insulin Administration Through Redesigning Processes of Care: A Multidisciplinary Team Approach

Citty, Sandra Wolfe ARNP-BC, PhD*; Zumberg, Lisa PharmD; Chappell, Justina ARNP-BC, DNP

doi: 10.1097/PTS.0000000000000128
Original Articles

Objectives This article describes a quality improvement project using a multidisciplinary team approach to improve the rate of errors of omission of preprandial subcutaneous coverage insulin orders.

Methods A Diabetic Management Work Group was created to evaluate the system processes that affect success and failure of timely administration and documentation of preprandial coverage insulin, commonly referred to as sliding scale coverage. Data before and after the project were collected to evaluate the effectiveness of a process change through the bar code medication administration system, in which preprandial coverage insulin order sets were changed to eliminate errors of omission and improve documentation.

Results A review of 833 random blood glucose measurements with corresponding short- or rapid-acting insulin coverage orders was conducted. A mean error of omission rate of 23.4% was identified with respect to coverage insulin that was clinically indicated by provider-ordered insulin set but not administered or documented in the electronic medication record. After process redesign and implementation, 951 blood glucose measurements with corresponding insulin coverage orders were randomly reviewed, and a mean of 10.7% of omission rate for coverage insulin administration was identified. This represented a decrease in omission of coverage insulin by 54% compared with preprocess improvement.

Conclusions Decreased errors of omission as well as improved administration and documentation of coverage insulin were demonstrated by this multimodal process change. Scheduled standardized order sets, extensive nursing staff education, and enhanced efficiency of the existing process led to improved outcomes.

From the *College of Nursing, University of Florida; and †North Florida/South Georgia Veteran's Affairs Medical Center, Gainesville, Florida.

Correspondence: Sandra Wolfe Citty, ARNP-BC, PhD, College of Nursing, University of Florida, PO Box 100187, Gainesville, FL 32610 (e-mail:

The authors disclose no conflict of interest.

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