Prevention of Catastrophic IV insulin overdose using the Insulin Guard
Care Process & Redesign
National Healthcare Innovation and Productivity Medals
SingHealth
31 December 2020
To eliminate IV insulin overdoses through innovative design to bypass human error. Insulin Guard successfully eliminated overdose risks and ensured safe insulin administration.
Year Submitted: 2020
Published Date: 31 December 2020
Tags: Care Process ＆ Redesign, Quality Improvement, Clinical Practice Improvement, Design Thinking, Risk Management, Preventive Approach, Value Based Care, Safe Care
About this Content
Aims
To eliminate IV insulin overdoses through innovative design to bypass human error.
Background
IV insulin overdoses cause severe complications, including neuroglycopenia, seizures, and death.
Methods
Designed and implemented an Insulin Guard to allow only insulin syringes to access insulin vials; prototypes validated with 3D printing.
Results
No IV insulin overdose cases reported post-implementation over 1 year; enhanced patient safety and reduced human error.
Conclusion
Insulin Guard successfully eliminated overdose risks and ensured safe insulin administration.
Lessons Learnt
Innovative tools, combined with staff buy-in and infection control support, are critical for success.
Additional Information
Recognized for enhancing patient safety through innovative solutions.
Keywords
Insulin Guard, IV Insulin, Hyperkalemia, Patient Safety, Root Cause Analysis
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | SingHealth |
Organization(s) Involved | Changi General Hospital |
Platform(s) | National Healthcare Innovation and Productivity Medals |
Healthcare Professional Group(s) | Nursing, Medical |
Applicable Specialty or Discipline | Endocrinology |
Project Lead(s) | Tay Tunn Lin |
Project Member(s) | Vernon Chen |
Connect with this contributor!
Tay Tunn Lin - Tay.tunn.lin@singhealth.com.sg