Table 4

High-risk industry failures and potential solutions

High-risk industry level
  • Diabetes education does not highlight similarity in insulin pens (eg, colour of rapid-acting vs long-acting pen); patient does not remember or realise the difference

  • Wrong insulin pen used; incorrect dose; incorrect type of insulin

  • Patient experiences symptomatic hypoglycaemia (≤70 mg/dL) or symptomatic hyperglycaemia (250–349 mg/dL)

7Medication use
  • Similarity of insulin pens

Patient education
  • Variation in training by endocrinology/diabetes providers/educators in addressing the similarities of pens

  • Not all pens are available for inpatient teaching; potential failure not detected

Containment solution:
  • Instructions highlighting the design similarities of insulin pens during education

Permanent solution:
  • Add provision to FDA approval mechanism (release to market approval) for improved differentiation of pens (type/design)

  • Contradicting DM medication instructions in different sections of discharge instructions

  • DM postdischarge medication error leading to symptomatic hypoglycaemia (≤70 mg/dL) or symptomatic hyperglycaemia (250–349 mg/dL)

7Healthcare information technology, Leadership
  • Lack of integration of discharge instructions from multiple care teams, specifically for high-risk medications

  • Automated discharge medication list does not provide accurate discharge instructions

Human factors and communication
  • Transcription error when discharge instructions are manually integrated

  • Complexity of instructions

Containment solutions:
  • Primary inpatient service/team or pharmacist integrates medication discharge instructions and removes duplicate, conflicting entries

  • Create an EHR ‘work around’ to permit flexibility of high-risk medication (eg, insulin) discharge instructions

Permanent solution:
  • Use of user (provider/patient) centred design methods in creation of electronic health record software for discharge instructions for high-risk medications such as insulin

  • Lack of/incorrect verification of whether DM medication(s) and supplies are covered by patient’s insurance

  • Prescriptions/supplies not covered by insurance; patient experiences symptomatic hyperglycaemia (250–349 mg/dL)

  • Delay in patient being able to fill prescription and taking DM medication

7Information management
  • Lack of a system where providers can easily verify patient coverage and patient-specific out-of-pocket payments to enable shared decision-making

Containment solution:
  • Provide patient with samples of covered pharmaceutical supplies or medications prior to discharge

Permanent solution:
  • Automated EHR function that verifies insurance coverage of prescribed medications and/or supplies

  • CI, Criticality Index; D, detection; DM, diabetes mellitus; EHR, electronic health record; F, frequency; FDA, Food and Drug Administration; H, harm; RPN, Risk Priority Number.