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RES239
Errors in interpretation of a Tight Glycemic Control (TGC) Protocol
By: B. Faddoul, A. Sowan, K.Johnson, A. Lee, K. Silver, & V. Vaida; University of Maryland Medical Center; Baltimore, MD
For further information, please contact: bfaddoul@umm.edu
Purpose: The purpose of this study was to use simulated clinical scenarios to identify the frequency and magnitude of errors resulting from misinterpretation of a nurse-driven paper-based (ND-PB) TGC protocol.
Background/Significance: Tight glycemic control has reduced mortality and morbidity in ICU patients. TGC is typically achieved by using ND-PB protocols. However, such protocols often have complex instructions, are prone to misinterpretation and insulin dosing errors. Protocol interpretation errors have not been previously studied.
Methods: Sixty two ICU nurses were given seven simulated TGC scenarios. Each scenario included a clinical case description, a current insulin dose, and new and prior blood glucose levels. Standardized instructions on using the paper-based TGC protocol were given at the start of the study, and nurses were required to interpret the protocol and indicate the correct new insulin dose. Incorrect responses were defined as an insulin dose indicated by the participant that differed by + 0.5 units/hour from the correct dose as determined from the protocol.
Results: A total of 434 responses were recorded from the participants (62 nurses times 7 scenarios). 96 of 434 (22%) responses had an insulin dosing error of greater than + 0.5 units/hour. The magnitude of the dosing errors ranged from -12 units/hour below to +7 units/hour above the correct dose. Of the 96 incorrect responses, 72 (75%) had an error where the dose indicated by the nurses differed by more than 20% from the correct dose.
Conclusions: This study showed that misinterpretation of TGC protocol is common and can result in large insulin dosing errors. Use of simulation-based testing can uncover potential errors before they reach patients and may provide the impetus to simplify complex ND- PB protocols or to use computerized protocols.
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