Bain Amie, Nettleship Lois, Kavanagh Sallianne, Babar Zaheer-Ud-Din
School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH United Kingdom.
Pharmacy Department, Sheffield Teaching Hospital NHS Foundation Trust, Herries Road, Sheffield, S5 7AU United Kingdom.
J Pharm Policy Pract. 2017 Aug 22;10:25. doi: 10.1186/s40545-017-0113-y. eCollection 2017.
Prescribing errors at the time of hospital discharge are common and could potentially lead to avoidable patient harm, especially when they involve insulin, a high-risk medicine widely used for the treatment of diabetes mellitus. When information regarding insulin therapy is not sufficiently communicated to a patient's primary care provider, continuity of care for patients with diabetes may be compromised. The objectives of this study were to investigate the nature and prevalence of insulin-related medication discrepancies contained in hospital discharge summaries for patients with diabetes. A further objective was to examine the timeliness and completeness of relevant information regarding insulin therapy provided on discharge summaries.
The study was undertaken at a large foundation trust hospital in the North of England, UK. A retrospective analysis of discharge summaries of all patients who were being treated with insulin and were included in the 2016 National Inpatient Diabetes Audit was conducted. Insulin regimen information provided on discharge summaries was scrutinised in light of available medical records pertaining to the admission and current national recommendations.
Thirty-three (79%) out of the 42 patients included in the study had changes made to their insulin regimen during hospital admission. Eighteen (43%) patients were identified as having an error or discrepancy relating to insulin on their discharge summary. A total of 27 insulin errors or discrepancies were identified on discharge, most commonly involving non-communication of an insulin dose change ( = 8) and wrong insulin device ( = 7). Seventeen issues relating to completeness of insulin information were identified, including the omission of the prescribed time of insulin administration ( = 10) and unexplained insulin dose change ( = 4). Two patients who had insulin-related errors identified on their discharge summaries were readmitted to hospital within 30 days of discharge due to poor diabetic control.
This small-scale study demonstrates that errors and discrepancies regarding insulin therapy on discharge persist despite current insulin safety initiatives. Poorly communicated information regarding insulin therapy may jeopardise optimal glycaemic control and continuity of patient care. Insulin-related information should be comprehensively documented at the point of discharge. This is to improve communication across the interface and to minimise risks to patient safety.
出院时的处方错误很常见，可能会导致可避免的患者伤害，尤其是当错误涉及胰岛素时，胰岛素是一种广泛用于治疗糖尿病的高风险药物。当有关胰岛素治疗的信息未充分传达给患者的初级保健提供者时，糖尿病患者的护理连续性可能会受到影响。本研究的目的是调查糖尿病患者出院小结中与胰岛素相关的用药差异的性质和发生率。另一个目的是检查出院小结中提供的有关胰岛素治疗的相关信息的及时性和完整性。
该研究在英国英格兰北部的一家大型基础信托医院进行。对2016年全国住院糖尿病审计中所有接受胰岛素治疗的患者的出院小结进行了回顾性分析。根据与入院相关的现有病历和当前的国家建议，对出院小结中提供的胰岛素治疗方案信息进行了审查。
该研究纳入的42例患者中，有33例（79%）在住院期间胰岛素治疗方案发生了变化。18例（43%）患者的出院小结被确定存在与胰岛素有关的错误或差异。出院时共发现27处胰岛素错误或差异，最常见的是胰岛素剂量变化未传达（n = 8）和胰岛素装置错误（n = 7）。发现17个与胰岛素信息完整性有关的问题，包括胰岛素给药规定时间的遗漏（n = 10）和无法解释的胰岛素剂量变化（n = 4）。两名出院小结中发现有胰岛素相关错误的患者在出院后30天内因糖尿病控制不佳再次入院。
这项小规模研究表明，尽管目前有胰岛素安全措施，但出院时胰岛素治疗的错误和差异仍然存在。关于胰岛素治疗的信息沟通不畅可能会危及最佳血糖控制和患者护理的连续性。胰岛素相关信息应在出院时全面记录。这是为了改善交接过程中的沟通，并将患者安全风险降至最低。
