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double-checking, subcutaneous insulin, medication errors, high-reliability organizations


BACKGROUND: With the epidemic of diabetes mellitus projected to rise from 1 in 10 U.S. adults (year 2010) to 1 in 3 by the year 2050, there is a need for health care organizations to prepare nurses to manage the complexity of meeting the needs of patients with diabetes, especially in the timely administration of subcutaneous insulin. The traditionally accepted practice of double-checking subcutaneous insulin before administration, albeit non-evidence-based, poses a clinical problem by imposing an unnecessary demand on nurses’ workload, which places an obstacle to their timely administration of time-critical subcutaneous insulin.

PURPOSE: This project aimed to examine if there would be a difference in medication errors surrounding nurses’ subcutaneous insulin administration when their system is altered from an independent double-checking to a single-checking environment.

METHODS: This quasi-experimental project was composed of a two-phase pilot study, with the first (double-checking) acting as the control and the second (single-checking) acting as the interventional phase.

RESULTS: Over a seven-week period, there were a total of 1,528 opportunities for subcutaneous insulin administration and omission in both phases among the 92 patients included in the sample. There was no significant difference in the “any one error” rates between the double-checking and single-checking phases. Of administration error types, “wrong-time” was predominant and more prevalent during the double-checking phase, which took an average of 11.7 minutes longer.

CONCLUSIONS: The traditional double-checking process did not significantly reduce medication error rates and contributed to a longer time lapse from blood glucose check to insulin administration.

Clinical Institute

Kidney & Diabetes








Thesis completed for Master of Nursing Program at Vanguard University of Southern California. Thesis advisor was Dr. Annette Callis.

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