Nursing Department, National University Hospital, Singapore.
Singapore National University Hospital Centre for Evidence-Based Nursing: A JBI Centre of Excellence, Singapore.
JBI Evid Implement. 2024 Aug 1;22(3):291-302. doi: 10.1097/XEB.0000000000000437.
Omission of insulin, a high-alert medication with one of the highest locally reported errors, could lead to severe hyperglycemia, which could result in coma or death if not treated timeously. This study aimed to identify, evaluate, and implement strategies to reduce the occurrence of insulin omission errors in diabetic adult patients requiring insulin.
This project followed the JBI Evidence Implementation Framework and conducted context analysis, strategy implementation, and evaluation of outcomes according to evidence-based quality indicators. The JBI PACES and JBI GRiP situational analysis tools were used to support data collection and implementation planning. There was one evidence-based criterion and five sub-criteria, with a sample size of 22 patients.
There was increased compliance with best practices to reduce interruptions and distractions from baseline audit (50%) to follow-up audits 1 (45.4%) and 2 (31.8%), and no insulin omission incidences during the implementation period. In the post-implementation analysis, there were notable improvements in compliance with strategies related to nurses; however, reduced compliance was observed related to patients. Key barriers to implementation included patients still disturbing nurses despite the nurses wearing the medication vests and patients forgetting instructions not to disturb nurses during medication administration. Strategies to improve compliance included ensuring coverage in each cubicle during insulin preparation and administration, tending to patients' needs prior to insulin administration, and use of posters as reminders.
There was an overall increase in compliance with best practice to reduce interruptions and distractions and no insulin omission incidences related to interruptions and distractions during the implementation phase.
胰岛素是一种高警示药物，其错误率在当地报告中属于较高水平，如果漏用，可能导致严重的高血糖，如果不及时治疗，可能导致昏迷甚至死亡。本研究旨在识别、评估和实施策略，以减少需要胰岛素的成年糖尿病患者胰岛素漏用错误的发生。
本项目遵循 JBI 证据实施框架，根据循证质量指标进行了背景分析、策略实施和结果评估。使用 JBI PACES 和 JBI GRiP 情境分析工具来支持数据收集和实施计划。有一个循证标准和五个子标准，样本量为 22 名患者。
与基线审核（50%）相比，在随访审核 1（45.4%）和 2（31.8%）时，减少干扰和分散注意力的最佳实践的遵守率有所提高，且在实施期间没有发生胰岛素漏用事件。在实施后分析中，与护士相关的策略的遵守率有显著提高；然而，与患者相关的策略的遵守率有所下降。实施的主要障碍包括尽管护士穿着药物背心，患者仍会干扰护士，以及患者忘记了在给药期间不要打扰护士的指示。提高遵守率的策略包括在胰岛素准备和给药期间确保每个小隔间都有人值班，在给药前满足患者的需求，以及使用海报作为提醒。
在实施阶段，总体上提高了减少干扰和分散注意力的最佳实践的遵守率，并且没有因干扰和分散注意力而导致胰岛素漏用事件的发生。
