FAILURES IN THE PRACTICES OF PREPARATION AND ADMINISTRATION OF INSULINS: SITUATIONAL DIAGNOSIS FOR PATIENT SAFETYABSTRACT
Objective: to map failures related to insulin preparation and administration practices in healthcare settings, from the comparative perspective of frontline professionals and experts.
Method: a cross-sectional observational study conducted with 86 healthcare professionals, including frontline workers from a hospital in Fortaleza-Ceará and experts in the field, carried out between August 2023 and April 2024. A tool with 20 multiple-check items, divided into six domains, was used to identify the main errors and adverse events related to patient safety resulting from insulin preparation and administration practices in clinical care.
Results: the most frequently reported inconsistencies by healthcare professionals were: failure to rotate insulin injection sites; use of inappropriate abbreviations and symbols in insulin prescriptions; in-use vials without a label indicating the opening date; improper storage of insulins; incorrect timing between insulin administration and meals; and disposal of sharps related to treatment in inappropriate locations. The identification of the following aspects was significantly higher among expert professionals: "In-use insulin vials without a label indicating the opening date," "Storage of insulins and heparins near refrigerators, and "Administration of insulin using large needles with improper angulation or without creating a skinfold."
Conclusion: these findings are significant as they serve as indicators of patient safety, contributing to the re-planning of actions aimed at improving the quality of care provided to people with diabetes.
DESCRIPTORS:
Health staff; Diabetes mellitus; Insulin; Boas práticas de manipulação; Patient safety
RESUMO
Objetivo: mapear as falhas relacionadas às práticas de preparo e administração de insulinas em ambientes de cuidados de saúde, sob a ótica comparativa de profissionais assistenciais e especialistas.
Método: estudo observacional transversal conduzido com 86 profissionais de saúde, incluindo assistenciais de um hospital em Fortaleza-Ceará e experts na área, realizado entre agosto de 2023 e abril de 2024. Utilizou-se um instrumento com 20 itens de múltipla checagem, divididos em seis domínios, para identificar os principais erros e eventos adversos relacionados à segurança do paciente decorrentes das atividades de preparo e administração de insulinas na prática assistencial.
Resultados: as inconsistências mais apontadas pelos profissionais de saúde foram: não realização de rodízios nos locais de aplicação das insulinas; uso de abreviaturas inadequadas e símbolos na prescrição de insulinas; frascos em uso sem registro (etiqueta) da data de abertura; acondicionamento inadequado das insulinas; intervalo incorreto entre a administração de insulina e a refeição; e descarte de material pérfurocortante relacionado ao tratamento em local inapropriado. A identificação dos aspectos “Frascos de insulina em uso sem registro (etiqueta) da data de abertura”, “Armazenamento de insulinas e heparinas em setores próximos à geladeira” e “Administração de insulina com agulhas grandes, realizando angulação inadequada ou sem fazer a prega subcutânea” foi significativamente maior entre os profissionais experts.
Conclusão: tais achados são importantes, pois consistem em indicadores de segurança do paciente, contribuindo para o replanejamento de ações voltadas à melhoria da qualidade da assistência prestada à pessoa com diabetes.
DESCRITORES:
Pessoal de saúde; Diabetes mellitus; Insulina; Boas práticas de manipulação; Segurança do paciente
RESUMEN
Objetivo: identificar las fallas relacionadas con las prácticas de preparación y administración de insulina en ambientes asistenciales, desde la perspectiva comparativa de profesionales de salud y expertos.
Método: estudio observacional transversal realizado con 86 profesionales de salud, entre auxiliares de un hospital de Fortaleza-Ceará y expertos en el área, entre agosto de 2023 y abril de 2024. Se utilizó un instrumento con 20 ítems de verificación múltiple, divididos en seis dominios, para identificar los principales errores y eventos adversos relacionados con la seguridad del paciente resultantes de las actividades de preparación y administración de insulina en la práctica asistencial.
Resultados: las inconsistencias más frecuentemente señaladas por los profesionales sanitarios fueron: no rotar los lugares de aplicación de la insulina; uso de abreviaturas y símbolos inapropiados en la prescripción de insulinas; viales en uso sin registro (etiqueta) de la fecha de apertura; envasado inadecuado de las insulinas; intervalo incorrecto entre la administración de insulina y una comida; y eliminación de los objetos punzantes relacionados con el tratamiento en un lugar inapropiado. La identificación de los aspectos «Viales de insulina en uso sin registro (etiqueta) de la fecha de apertura», «Almacenamiento de insulinas y heparinas en sectores próximos a la heladera» y «Administración de insulina con agujas grandes, realizando una angulación inadecuada o sin hacer el pliegue subcutáneo» fue significativamente mayor entre los profesionales expertos.
Conclusión: estos hallazgos son importantes por ser indicadores de la seguridad del paciente, contribuyendo a la replanificación de las acciones dirigidas a mejorar la calidad de la atención prestada a las personas con diabetes.
DESCRIPTORES:
Personal sanitario; Diabetes mellitus; Insulina; Buenas prácticas de manipulación; Seguridad del paciente
INTRODUCTION
Patient safety is a global public health issue that demands universal and effective safeguards within healthcare systems. Harm caused to patients due to unsafe practices and medication-related failures ranks among the leading causes of illness worldwide and is the primary source of preventable errors globally1.
Understanding the processes involved in medication administration practices is essential for developing strategies to mitigate errors in healthcare settings2. To this end, conducting a situational diagnosis is crucial to identifying process failures.
A situational diagnosis consists of the outcome of a data collection and analysis process conducted in a specific location, supporting the establishment of priorities based on institutional and population realities to identify problems. Thus, it becomes an important health management tool, particularly in research on conditions and risks affecting specific populations, aiding in strategic planning and action programming. It allows for an understanding of healthcare service organization by identifying and analyzing priority institutional needs, being essential for establishing demands that require adjustments to achieve more qualified care management2.
Within the scope of care management for diabetes mellitus (DM), pharmacological management through insulin therapy stands out. According to the Institute for Safe Medication Practices, insulin is classified as a potentially dangerous medication (PDM) or high-alert drug. Medications in this category carry an increased risk of significant harm due to usage errors. Therefore, having trained and up-to-date healthcare professionals on the management of this medication is a priority to ensure effective care that prioritizes patient safety3.
Despite its recognized risk potential, insulins are medications used both in hospital and outpatient settings, making it essential for healthcare professionals to establish a continuous education process linked to surveillance and monitoring systems. The goal is to identify and prevent errors related to the use of these drugs. In this regard, medication error prevention programs should pay special attention to insulins4.
Errors in insulin preparation and administration are frequently identified by healthcare professionals, compromising patient safety. These errors include: inappropriate doses due to the use of abbreviations and symbols in prescriptions; mistakes in syringe calibration (mL instead of international units); incorrect administration of insulin type (rapid-acting instead of basal); inappropriate intervals between insulin administration and meals; lack of suspension homogenization for certain insulins; and issues with programming insulin pumps in inpatient units5.
Good practices in insulin therapy can minimize or prevent errors associated with administration failures, enhancing its therapeutic effect, reducing pain, and improving metabolic control and quality of life for people with DM, especially those on regimens requiring multiple daily insulin injections6. In this context, promoting safe practices in insulin therapy is crucial, encompassing all related aspects6.
In pursuit of organizing diabetes care services, defining processes and monitoring mechanisms is essential. These should be organized practically for services and activities, documented in the form of procedural models. Protocols and indicators related to the care of individuals undergoing insulin therapy are scarce and should be utilized by relevant sectors as guidelines for executing work process stages in accordance with established criteria and assigned responsibilities7-8.
In this regard, aiming to obtain a situational diagnosis on the safety of patients with diabetes mellitus undergoing insulin therapy, this study sought to map failures related to insulin preparation and administration practices in healthcare environments, from the comparative perspective of frontline professionals and experts.
METHOD
This is a cross-sectional observational study, of the situational diagnostic type, conducted with 86 healthcare professionals: 40 frontline workers from a reference hospital in Fortaleza, Ceará, and 46 experts in the thematic area, between August 2023 and April 2024. The objective was to identify the main errors and adverse events related to patient safety resulting from insulin preparation and administration practices in clinical care.
A mapping approach was chosen that included both frontline professionals and experts in the field to assess whether increased technical knowledge acted as a contributing factor in identifying failures in care practices and, consequently, in enhancing the safety of patients with diabetes undergoing insulin therapy.
Experts were professionals trained in the field and with practical experience in caring for people with diabetes, selected from the five Brazilian regions according to criteria proposed by Jasper9. According to this author, an expert in a specific area must meet the following requirements: possess knowledge and skills acquired through experience; have specialized knowledge and competencies that make them an authority on the subject; demonstrate specific expertise in a particular type of study; pass a designated test to identify experts; and receive high ratings or titles attributed by an authority.
For this study, it was stipulated that participants (experts) should meet at least two of the above requirements to be considered specialists in the thematic area. Each requirement was achieved by summing related characteristics, verified through consultation of the participants' curricula on the Lattes Platform. Chart 1 details the requirements and adapted characteristics for defining a clinical expert.
Requirements for defining a clinical expert, as proposed by Jasper (1994)9, according to respective specific characteristics, Fortaleza, CE, Brazil, 2024.
The instrument used to identify failures related to insulin preparation and administration practices was developed based on recommendations from relevant scientific societies6,10. It contains 20 multiple-check items divided into six domains: risk behaviors related to failures in documentation records in healthcare environments; use of inappropriate instruments for insulin administration, causing imprecision in calibration and errors in the administered dose; failures in insulin storage; failures in insulin preparation; failures in insulin administration; and failures in the disposal of sharps related to diabetes treatment.
Through remote communication via email, professionals were informed about the study and invited to participate. Those who agreed signed the Free and Informed Consent Form (FICF). Each professional was free to list, without a maximum limit, all failures related to insulin preparation and administration practices experienced in their work process, enabling the identification of key problems in diabetes care. This formed the basis for constructing a situational diagnosis for the planning and strategic programming of actions aimed at improving the quality and safety of care for people with diabetes mellitus.
The data obtained through the mapping of failures were processed and analyzed using the Statistical Package for the Social Sciences version 29.0. Measures of central tendency and dispersion were evaluated and presented in tables with absolute and relative frequencies.
The study adhered to the ethical requirements established in national and international regulations governing research involving human subjects and was approved by the Research Ethics Committees.
RESULTS
Among the professionals who participated in the research on failures related to insulin preparation and administration practices, there was a predominance of women, with an average age of 33.5 ± 8 years. The most prevalent professional category was nurses (45; 52%). The average length of professional experience (13.7 ± 10.3 years) and experience in the diabetes field (8.8 ± 6.9 years) was significantly higher in the expert group compared to frontline professionals.
Regarding academic qualifications, a significantly higher prevalence of master’s degree holders (25; 54%) and doctoral degree holders (11; 24%) was observed in the expert group, in contrast to frontline professionals (Table 1).
The most frequently reported errors by healthcare professionals were: lack of rotation of insulin injection sites; use of inappropriate abbreviations and symbols in insulin prescriptions; in-use insulin vials without a label indicating the opening date; improper storage of insulins; inappropriate timing between insulin administration and meals; and disposal of sharps related to diabetes treatment in inappropriate locations.
Additionally, expert professionals identified the following aspects with greater frequency: “In-use insulin vials without a label indicating the opening date,” “Storage of insulins and heparins near refrigerators,” and “Administration of insulin with large needles, improper angulation, or without creating a skinfold” (Table 2).
DISCUSSION
The situational diagnosis, developed based on the mapping of the main failures in insulin preparation and administration practices, allowed for the identification of the most significant weaknesses in insulin therapy care for people with diabetes.
Among the most frequently mentioned failures by healthcare professionals are: lack of rotation of insulin injection sites; improper storage of insulins; use of inappropriate abbreviations and symbols in prescriptions; and absence of labeling indicating the opening date on in-use insulin vials.
Regarding the rotation of injection sites, the literature reinforces the risks associated with non-compliance with this practice. Repeated injections in specific areas can increase the risk of adverse events, such as lipodystrophy. It is essential that rotation be performed systematically, considering the identification of injection sites and maintaining a minimum distance of 1.5 cm between injections, avoiding the reuse of the same site for at least 20 days. This effective practice helps reduce glycemic variability and prevent local complications, while also improving metabolic control6,11.
When performed randomly, site rotation can cause variations in insulin absorption. Thus, proper planning should consider the number of daily injections, dosing times, physical activity levels, and other factors that may affect insulin absorption rates6.
Another inconsistency highlighted in this study, consistent with the literature8, is the improper storage of insulins. Examples include storing them on the refrigerator door, in the freezer, or in locations exposed to high temperatures or direct sunlight. As a safe practice, it is recommended that sealed vials, cartridges, and disposable pens be kept refrigerated between 2 and 8°C until their expiration date. In-use insulins, however, can be stored at room temperature (up to 30°C) for the period specified by the manufacturer. If frozen, insulin must be discarded, as extreme temperatures compromise its potency and action12.
Risk behaviors related to documentation failures in diabetes care settings emerged as another significant weakness in this study, particularly regarding the use of inappropriate abbreviations and symbols in insulin prescriptions, such as "U" and "IU" instead of the word "units." This practice can lead to misinterpretations of prescribed doses. Additionally, the absence of labeling indicating the opening date on in-use insulin vials poses a risk of using insulin beyond its recommended expiration period.
These results align with the literature, which identifies recording and communication failures-including the use of abbreviations, transcription errors, inadequate verification and calculations, as well as prescription mistakes as contributing factors to errors in the insulin administration process13.
Another critical issue identified was the lack of labeling on in-use insulin vials, which may result in administering insulin beyond the recommended timeframe, typically ranging from 28 to 56 days after opening, as specified in pharmacological and manufacturer guidelines6,14.
In this context, the importance of secure documentation for effective record management becomes evident. The challenge lies not only in ensuring quick and clear access to information but also in guaranteeing the integrity, reliability, and confidentiality of data provided by healthcare system users15.
Records document the care provided, enabling a continuous flow of information and facilitating safe communication among healthcare team members. Moreover, they are essential for care planning, promoting knowledge and health education, and serving as evaluative criteria for the quality, efficiency, and effectiveness of care16.
To achieve these objectives, records must be detailed, complete, and clearly written. The use of abbreviations, acronyms, and erasures should be avoided, prioritizing legibility and computerized documentation whenever possible. Records should include information such as the date, time, and identification of the responsible professional, ensuring a quality standard that contributes to patient safety15.
These findings underscore the importance of systematizing ongoing educational actions in healthcare services to raise awareness among professionals about the relevance of proper documentation for the safety of people with diabetes. This can minimize risky behaviors related to documentation failures in care settings, such as errors in prescription interpretation or the use of insulin past its expiration date due to the lack of labels indicating the opening date of in-use insulin vials.
Another point reinforcing the importance of ongoing education for adherence to safe insulin preparation and administration practices is that, in this study, the identification of aspects such as “In-use insulin vials without labeling of the opening date,” “Storage of insulins and heparins near refrigerator sections,” and “Administration of insulin with large needles, improper angulation, or without creating a skinfold” was significantly higher among diabetes expert professionals. This highlights the importance of increased professional knowledge as a collaborative factor for patient safety.
An investigation analyzing the relationship between education and adherence to diabetes self-care practices showed that compliance with insulin therapy improved after diabetes education interventions, demonstrating the effectiveness of such measures in promoting safe insulin therapy8. Thus, ongoing education for both healthcare teams and patients is directly linked to error identification and the establishment of strategies to improve the quality of care for people with diabetes17.
As limitations of the study, it is important to note that data collection from frontline professionals was conducted in only one institution. Additionally, the mapping was based solely on healthcare professionals’ perceptions, which may involve weaknesses and subjectivity, such as forgetfulness or lack of attention to capturing information across all stages of the safe insulin preparation and administration process.
In terms of contributions to clinical practice and improving the safety of people with diabetes, this study enabled the creation of a situational diagnosis by identifying the main failures in insulin preparation and administration practices. Therefore, it is suggested to implement an ongoing education plan based on validated protocols, focusing on the safe storage and administration of insulin, as well as improving documentation quality in care settings. These findings support the planning of actions aimed at enhancing clinical care and patient safety.
CONCLUSION
The study mapped the main failures in insulin preparation and administration practices as identified by frontline professionals and experts. The most prevalent failures were: failure to rotate insulin injection sites; documentation-related issues; improper storage; inappropriate timing between insulin administration and meals; and improper disposal of sharps.
These findings are highly relevant as they enabled the development of a situational diagnosis through patient safety indicators, contributing to the replanning of actions aimed at improving the quality of care for people with diabetes. Furthermore, they highlight the importance of ongoing education for healthcare professionals as a strategy to promote safe and efficient practices in patient care.
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NOTES
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ORIGIN OF THE ARTICLE
Extracted from the thesis - Protocol on Safe Practices for Insulin Preparation and Administration: A Potentially Dangerous Medication, presented to the Graduate Program in Clinical Nursing and Health Care at the State University of Ceará, 2024.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Universidade Estadual do Ceará and the Hospital Universitário Walter Cantídio, under opinions no. 5,373,194 and no. 5,409,529, Ethical Appreciation Presentation Certificates 56785422.2.0000.5534 and 56785422.2.3001.5045.
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TRANSLATED BY
Agência Latintrad - Leonardo Parachú
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DATA AVAILABILITY
The entire dataset supporting the results of this study is available upon request to the corresponding author Tatiana Rebouças Moreira. The dataset is not publicly available because it is part of a doctoral thesis, for which a portion of the data remains to be published.
Edited by
The entire dataset supporting the results of this study is available upon request to the corresponding author Tatiana Rebouças Moreira. The dataset is not publicly available because it is part of a doctoral thesis, for which a portion of the data remains to be published.
