Insulin is a high-risk medication and can lead to significant morbidity and mortality, especially in young children who require smaller, weight- based dosing. It is also one of the most common medications listed in incident reports within inpatient pediatric units at University of California Davis Children’s Hospital (UCDCH) due to manual calculation and entry errors. We sought to answer, does the use of a MAR based insulin calculator reduce the number subcutaneous insulin dose errors for an inpatient children’s hospital? A MAR based insulin calculator was configured into Epic Hyperspace, insulin order sets were updated, nursing policies were updated, communication tools were delivered to advise staff of new calculator workflow, and inpatient pediatric nurses were assigned an electronic learning module. Nurse champions were trained on the calculator and were utilized for unit-based education and real time support. From January 2020 through January 2022, there were 53 subcutaneous insulin dosing errors in the inpatient pediatric setting at UCDCH. After implementation of the MAR based calculator there were 2 errors over an eight-week period. A MAR based insulin calculator reduced the number of subcutaneous insulin dose errors by 50% in a children’s hospital. A MAR based insulin calculator suggests safer inpatient use of insulin although more time is needed to evaluate the full scope of error reduction.
R.O. Lee: None. C. Schulmeister: None. D. Schauer: None. B.M. Bagley: None.
