Title : Insulin education for everyone
Abstract:
Medication safety requires the utmost of attention; high alert medications raise the bar. Having a child or family member diagnosed with Diabetes is a life-changing event. Trusting in the medical team brings a sense of calm but what if you doubt insulin safety at the hospital your child or family member is in? Our pediatric unit had an insulin error. One error is too much and we realized it could be preventable. Come listen to how one unit created an escape room centered on insulin safety; reinforcing nursing skills while having fun. Through apparent cause analysis, leadership identified unclear insulin orders, inconsistent orders, and needing reeducation as weaknesses. It soon became multi-disciplinary as we involved pharmacy, endocrinologists, intensivists, and nurses. The pediatric leadership team advocated for menus to include carbohydrates so staff can teach how to carb count in real time. Next was the electric medical record. First was getting insulin administration dual signature; second was getting the insulin sliding scale in the system and having a carb counting application added. Instituting this process also allowed us to collect data on the time it took from a blood glucose check to insulin administration. A family friendly flip chart was created. Nursing was given pens with a pull out banner that had the types of insulin, brand name, indication, onset, peak, duration, and route. The final part of the project was an escape room that was designed to depict a child in crisis from hypoglycemia. Using the plan-do-study-act cycles methods were improved based on feedback. Staff had to demonstrate knowledge and perform techniques so they could find clues that could help them escape. Competencies assessed were working under pressure, teamwork, and logical deductive thinking. Data collected has shown implementing a comprehensive insulin safety project that educates nurses, standardizes ordering and administration empowers nurses to feel confident.
