Insulin is one of the very essential drugs to be discovered in the history of medicine,and it is among the high-alert drugs. The drug’s therapeutic benefits cannot be undervalued, especially in the management of the critically ill patients suffering from diabetes. Although insulin is an important drug, errors associated with the drug are dangerous, both to the patient and the staffs handling the drug. However, although the insulin errors have continued to be a major problem in many hospitals, they are preventable. Research indicates that, although measures to prevent medication errors with insulin have been in place for more than a decade, the medication errors are still a prevalent issue associated with insulin use (Ramasamy, Bayasari, Lehnborn & Westbrook, 2013). Improving the safety of insulin use is thus, very important in achieving its efficiency in patient care. Some of the errors associated with insulin include administration of the wrong dose, omission of doses, wrong patient, using the wrong type of insulin, failing to adjust insulin therapy appropriately, improper assessment, timing and monitoring, and administering via the wrong route.

In order to maintain and guarantee insulin safety in hospitals, protocols are needed that should guide the procedures for the use of insulin. One major protocol that has been used in some hospitals is the use of two nurses to check for insulin before administering to the patient (Chant, Mustard, Thorpe & Friedrich, 2012). The safety of the two nurse check protocol is controversial, based on many factors such as the availability of nurses, adherence of nurses to the protocol, obvious human errors and nursing workloads. As such, many hospitals are reluctant to implement the two nurse check protocol. Some hospitals have gone ahead and eliminated the already launched two nurse insulin check protocol. In the hospital where did my clinical placements, the protocol was eliminated because the administration observed that it was causing delays in patient care, as a nurse on duty would wait for a second nurse to assist in checking the insulin. Eliminating the protocol may not promote patient safety, according to the Institute of Medicine’s (IOM) Quality and Safety Education for Nurses (QSEN) competencies (Dolansky & Moore, 2013).

Patient and provider safety is one of the five competencies for practice advocated by the IOM/QSEN. Considering the potential for errors in insulin use and administration, it is very paramount that all providers mind about its safety, especially to the diabetic patient. As seen from the errors associated with insulin administration, a wrong dose, wrong route, wrong type and other errors are very risky to the life of the patient. The two nurse insulin-checkprotocol aims at ensuring, improving, guaranteeing and maintaining patient and provider safety in the use and administration of insulin, in line with the requirements of the IOM/QSEN. In lieu of this, the essay investigates the safety of the two nurse insulin check protocol. The research paper attempts to answer the question: To what extent is two nurse insulin check protocol safe? This is an important concern to the nursing fraternity because it is a measure of promoting patient safety as encouraged by the Institute of Medicine (IOM) and the Quality and Safety Education for Nurses (QSEN) competencies (Dolansky & Moore, 2013). Ascertaining the degree of safety of the protocol will serve as a guide as to whether the protocol should be encouraged or discouraged. Such knowledge will lead to the institution of measures to enhance the implementation of policies and procedures related to the protocol, or doing away with the protocol all the same. The paper answers the research question through a literature search.

Review of Research Literature:

Olinghouse (2012) outlines some of the factors leading to medication errors the calculation of doses, human errors in the timing of doses, errors in setting the insulin pump, decimal-point errors, the deficitin the insulin therapy knowledge, miscommunication and inability to interpret the available client information. In line with these factors, it is evident that human nature is liable for errors in the use and administration of medications. Insulin is a sensitive medication; it needs sensitivity in the use and administration. Most of the factors identified lead to errors that can be eliminated through the use of two nurse insulin check protocol. The use of two nurses to check the calculation of doses, counter-check the rightness of the patient, and combine therapy knowledge during administration, reduces errors, improving the safety of insulin administration for a particular patient. As a pointer to the need to double-check insulin use and administration, Olinghouse (2012) concludes that; the effective implementation of the recommended protocols to double-check insulin use and administration will lead to the reduction of risks associated with the use of insulin. Such can be interpreted as safety being guaranteed by the use of double-checking insulin by two nurses before administration. On the same note, Chant, Mustard, Thorpe and Friedrich (2012) observe that; the implementation of second-person check protocol is an important milestone in guaranteeing patient safety with the use of insulin. According to Chant, Mustard, Thorpe & Friedrich (2012) the control of glycemic levels by only avoiding errors is only one, among the many milestones needed to guarantee patient safety. Deficiencies in monitoring and administering insulin therapy are among the leading causes of errors in insulin use. As such, achieving glycemic control should be a major goal in insulin therapy. In order to achieve this goal, one major protocol is the use of two nurse insulin check. Such an initiative would lead to effective management of patients, avoiding adverse patient outcomes.

According to Ramasamy, Bayasari, Lehnborn & Westbrook (2013), double-checking of medications by nurses has been seen to reduce patient risks that may lead to medication errors. However, these authors observe that double-checking is effective only when its importance is taken into account, rather than when performed as a routine task. There has been a tendency for nurses to perform the double-checking activity as if it is a routine activity, yet such cannot achieve the intended purpose of promoting patient safety. Ramasamy et al. (2013) argue that; even though many hospitals have drawn the double-checking procedures and policies, the implementation has been very inconsistent, leading to dilution of the intended purpose of promoting patient safety. In addition, the double-checking procedures for some hospitals do not contain explicit definitions, which leads to their being followed inconsistently. Further, Ramasamy et al. observe

The scarcity of research data documenting the effectiveness of double-checking in reducing patient errors is also a major limitation of the protocol (Ramasamy et al., 2013). Currently, the protocol lacks a concrete definition that can be used to develop procedures and policies that will ensure the protocol is implemented consistently. In essence, the currently available definitions do not clarify whether the second nurse should counter-check all the procedures with the first nurse as they are done or just check after the procedures have been done. For example, when calculating insulin doses, some hospitals advocate double checking as the calculations are done, while others only require the second nurse to check the calculations done by the first nurse. The lack of clarity in the procedures is a loophole for the double checking protocol, that can lead to risks, limiting the safety of the patient. In other words, the policies are not explicit as to what exactly needs to be checked. Ramasamy et al. advises that an effective protocol should be explicit that the second nurses should be able to countercheck all the probable risks in order to promote the safety of the patient. Regarding the effectiveness of double-checking as a method of ensuring patient safety with medications, Ramasamy et al. reiterated that; it is an effective method. However, these authors confirm that double checking is not all good for all the medications, but it is highly recommended for the high-alert medications like insulin. The authors mention time constraints as a major challenge to implementing the double checking protocol. However, the authors concur that medication errors have been prevalent even in hospitals where double-checking has been practiced.

When a computerized system of calculating insulin doses was compared with the double-checking protocol (Olinghouse, 2012), a computerized system is reported to be more effective in reducing errors. According to Olinghouse, the double-checking protocol and other labor-intensive protocols are not favorable for the current millennium, which is affected by a huge shortage the nursing staff. While Olinghouse faults the labor-intensive nature of the double-checking system, he does not doubt the effectiveness of the protocol in ensuring the patient’s safety, if implemented effectively. The author, however, faults the tendency by some staffs to consider some orders superior to others. According to the author, protocol orders are medication orders, and they should be followed to the letter. The lack of enough time and the fear of the development of hypoglycemia lead to the violation of protocols that are labor intensive. As such, the two nurse insulin-check protocol is likely to suffer from such blows if the nursing staffs are not enough.

While supporting the need for double-checking and the need to develop and adhere to the protocol, Cobaugh et al. (2007) assert that insulin errors during administration include, but are no limited to using insulin pens incorrectly, confusing names and administration of incorrect doses. The observations posed by Caubaugh et al. (2013) are in agreement with the lamentations of Olinghouse (2012) concerning the medication errors in the administration of insulin and the need for such a protocol like the double-checking protocol. In order to minimize errors and improve the safety of administration of insulin, Cobaugh et al. recommend that; all calculations should be left to the pharmacy department. However, Caubaugh’s team agrees that hospitals should have policies that will promote the safety of the administration, since errors are not limited to calculations. Through such an observation, the need for a double-checking protocol is realized, as a measure of ensuring nurses combine their knowledge and skills to promote ts led to the conclusion that; a nurse-directed glucose control is as effective as a nomogram directed glucose control. The authors recommend the use of nurse’s experience and judgement in the titration of insulin for the ICU patients. However, these authors fault the system of working in groups because of the need for autonomy, nurses’ satisfaction and the current incidence of nursing workloads.

The two nurse protocol is a nurse-led protocol of insulin administration and use. According to Khalaila et al. (2007) nurse led protocols of insulin administration have been found to be effective in the control of glycemic levels in the critically ill patients. According to these authors, a nurse-led protocol has been found to be associated with few cases of hypoglycemia levels as compared with the standard set procedures for glucose monitoring. Their findings support a nurse led double-checking of insulin before it is administered to the patients to maximize its safety.

Case Study Example:

This research paper is a clinical integration paper thatconnects to the case study in the hospital where I did my clinical placement. When I started working at the hospital, the two nurse insulin-check protocol was in place, and every nurse caring for a diabetic patient or such a case had to adhere to the protocol. However, by the time I left the hospital, the protocol had been eliminated. The protocol was eliminated because the heath care workers and the administrators felt that the protocol was causing delays in care as the nurses were always waiting for the second nurse to verify the insulin before administration. With time, it came to the attention of the administration that the second nurses were not always available to verify the insulin. At other times, the nurses were available but were overloaded with their patients, such that they could not leave the patients whom they were allocated to assist other nurses to countercheck the insulin. It became common in the hospital that all insulin administration delays were associated with the unavailability of second nurses to countercheck the insulin. The hospital administration called for a review board meeting and decided to eliminate the protocol as they observe the situation for some time.

The challenges associated with the two nurse insulin-check protocolhave been documented in the literature. Ramasamy, Bayasari, Lehnborn & Westbrook (2013) observed that nurse workloads, nurse shortages and disregarding the protocol, are among the major problems associated with the two nurse insulin protocol, threatening its safety. As encouraged by Chant, Mustard, Thorpe & Friedrich (2012), I also felt that the method should not have been eliminated in my hospital, but it should have been reinforced to promote the safety of the patients. The decision to eliminate the protocol does not guarantee safety to the patient. As Olinghouse (2012) advised, a medication protocol should be taken as serious as a medication order. The hospital administration should have looked for alternatives, better ways, or improve the implementation of the two nurse insulin protocol to ensure its effectiveness, thus the safety of the patients.

Conclusion:

The majority of the studies reviewed in this paper agree that the two nurse insulin-check before administration is a protocol that guarantees patient safety (Chant, Mustard, Thorpe & Friedrich, 2012; Olinghouse, 2012; Sharpe, 2012). The research articles also concur that the safest protocol in the use and administration of insulin has not been determined. A computerized system of calculating insulin doses may, in some way, exceed the safety of the two nurse insulin-check protocol (Olinghouse, 2012). However, calculation of doses is only a component of the many sources of errors that need double-checking during the use and administration of insulin. Thus, although two nurse insulin protocol has been faulted for being labor intensive, it is a bit more favorable. Many challenges have been identified as reasons for faulting the double-checking protocol. These include its labor intensive nature, the need for autonomy of nurses, the shortage of nurses and the huge nursing workloads. In order to promote the safety of the protocol, the protocol needs to be implemented with seriousness. The best practice is where the hospital culture promotes the application of the protocol just as a medication order (Olinghouse, 2012). The protocol needs to be integrated into the culture of the organization. While allocating nurses to their various duty stations, the nurse manager needs to consider the labor-intensive nature of the protocol. Such measures will deal with the challenge of unavailability of nurses.

Nurses need to be educated on the need to observe the safety of the patient and provider in line with the QESN guidelines (Dolansky & Moore, 2013). The current nursing guidelines for educating nurses about the care of patients in regard to insulin use and administration focus on safety and effective use (Sharpe, 2012). In essence, the education focuses on the importance of safety in the administration of insulin, being among the high-alert medications (Sharpe, 2012). In addition, nurse education emphasizes that staffs need to be updated about insulin therapy frequently. In the teachings, it should be emphasized that insulin medication errors are preventable, and the two nurse insulin-check for insulin medication should also be emphasized. In addition, it should be made clear that the two nurse insulin-check protocol is safe, but it should be implemented effectively.

Further research is needed to determine the safest protocol among the insulin administration protocols. In regard to the two nurse insulin-check protocol, further research needs to be directed to determining its safety in an ideal setting, where the challenging factors are held constant. In sum, the two nurse insulin-check protocol is a safe method. However, it is faced with many challenges that compromise its safety.

References

Chant, C., Mustard, M., Thorpe, K. E., & Friedrich, J.E. (2013). Nurse-versus normogram directed glucose control in a cardiovascular intensive care unit. American Journal of Critical Care, 21(4), 270-279.

Cobaugh, J.D., Maynard, G., Cooper, L., Kienle, C.P., Vigersky, R., Childers, D… & Cohen, M. (2013). Enhancing insulin safety in hospitals: Practical recommendations from an ASHP foundation expert consensus panel. American Journal of Health Systems Pharmacy, 70, 18-27.

Dolansky, M.A., & Moore, M.S. (2013). Quality and Safety Education for Nurses (QSEN): The key is systems thinking. The Online Journal of Issues in Nursing, 18(3), Manuscript 1. <http://www.nursingworld.org/Quality-and-Safety-Education-for-Nurses.html>

Khalaila, R., Libersky, E., Catz, D., Pomerantsev, E., Bayya, A., Linton. M.D., & Sigal, S. (2011). Nurse-led implementation of a safe and effective intravenous insulin protocol in a medical intensive care unit. Critical Care Nursing, 31(6), 26-36.

Olinghouse, C. (2012). Development of a computerized inravenous insulin application (AutoCal) at Kaiser Parmanente, Northwest, integrated into Kaiser Permanenete HealthConnect: Imact on safety and Nursing workload. The Permanente Journal, 16(3), 67-70.

Ramasamy, S., Baysary, T.M., Lehnborn, E.C., & Westbrook, J.I. (2013). Evidence briefings on interventions to improve medication safety: Double-checking medication administration. Australian Commission on Safety and Quality on Healthcare, 1(3), 1-4.

Sharpe, L. (2012). Improving safety of insulin administration: A pilot audit of hospital staff knowledge. Journal of Diabetes Nursing, 16(1), 8-16.

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