From the Wires
Insulin Administration and Nutritional Therapy Requires Standardized Coordination, Says ECRI Institute PSO
By: PR Newswire
Nov. 15, 2012 03:06 PM
Patient Safety E-lert, available now for free, addresses reported problems and includes new recommendations
PLYMOUTH MEETING, Pa., Nov. 15, 2012 /PRNewswire-USNewswire/ -- Insulin has consistently been declared a high-alert medication due to the risks associated with its prescribing and dosing. When a nutrition order for a patient is modified, the patient's insulin regimen may inadvertently remain unreviewed or unchanged. ECRI Institute Patient Safety Organization (PSO) has seen both events and research requests pertaining to this issue.
"Because diabetic and non-diabetic patients receiving nutritional therapy and insulin are often managed by more than one practitioner, facilities need to implement a standardized process to ensure coordinated care," states Karen P. Zimmer, MD, MPH, FAAP, medical director, ECRI Institute PSO. "Yet when we further explored this topic, there was minimal literature that discussed best practices and among the hospitals we approached, there was no consensus on how to best go about this. The analysis of aggregated reports continues to reveal gaps that we need to address."
ECRI Institute PSO's recently released Patient Safety E-lert, "It's More Than Counting Carbs, It's Communication and Coordination: Insulin Administration and Nutritional Therapy," highlights this patient safety issue involving patients who are receiving enteral or total parenteral nutrition and insulin. The issue came to light when ECRI Institute PSO analyzed reports submitted by participating healthcare providers. As part of its mission to research the best approaches to improving patient care, ECRI Institute is sharing this special E-lert with the healthcare community.
"Reports submitted to Patient Safety Organizations can surface less-known or undetected risks, like those highlighted in this report," states Barbara Rebold, RN, MS, CPHQ, director of operations, ECRI Institute PSO. "We want to share the potential risk we are seeing in our PSO reports and recommend ways to prevent or mitigate that risk."
For questions about this topic, or for information about ECRI Institute PSO, contact ECRI Institute by telephone at (610) 825-6000, ext. 5558; by e-mail at firstname.lastname@example.org; by fax at (610) 834-1275, or by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA. To sign up for the PSO Monthly Brief, a free eNewsletter comprised of a brief article each month to help keep readers informed about Patient Safety Organizations, go to www.ecri.org/psobrief.
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