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Sticking Together! A Creative Approach to Documenting Insulin Double Checks
Patient care and family teaching are the heart of the rehabilitation staff nurse’s role. Documentation of the various aspects of patient care and family teaching is a necessary but time-consuming process. In this article you will learn how the nurses of one rehabilitation center welcomed a creative time-saving method of working together to improve documentation compliance for double checking insulin administration. The development of the process, education of the staff, and the outcomes are included.
A 2004 National Patient Safety Goal recognized by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) was to “Improve the safety of high-alert medications” (JCAHO, 2004). Insulin was identified as one of these medications. The policy of The Ohio State University (O.S.U.) Medical Center includes the requirement of double checks by nurses prior to all insulin administration.
The acute inpatient rehabilitation facility of the O.S.U. medical center is ranked among the top 10 in the nation by U.S. News and World Report and also holds accreditations from JCAHO and the Commission on Accreditation of Rehabilitation Facilities.
Patients admitted for rehabilitation services receive expert nursing care, and documenting this care is a vital aspect of the nurse’s responsibility. The admitting nurse completes several pages of a comprehensive interdisciplinary database and enters Functional Independent Measure (FIM) scores, in addition to rehabilitation nursing issues and goals, on the interdisciplinary plan of care. Additional documentation includes teaching with the patients and their caregivers, weekly progress for FIM scores, and progress toward patient goals. A nurse may also be asked to serve as patient representative for the interdisciplinary team. This role includes documentation of meeting with the patient and caregiver to discuss team and patient goals. This initial documentation is then followed by weekly updates. With the exception of medication administration, all forms of documentation are hand written.
The rehabilitation facility has two inpatient nursing units. The third floor has 31 beds and the fourth floor has 29 beds. Daily nursing assignments are divided among teams, with four registered nurses designated as primary team leaders for day and evening shifts. Prior to meeting JCAHO’s 2004 goal mentioned above, the nurses consistently had insulin doses double checked by another nurse, but the documentation process was not well organized. The procedure in place consisted of both nurses being required to sign the diabetic flow sheet on the patient’s chart.
Because of the size and physical design of the nursing units, the nurses were asked to use costly time and precious energy for the purpose of cosigning a patient chart. In view of the fact that the nurse performing the double check may not be at liberty to leave his or her own patients in order to cosign a chart for a peer, compliance with the documentation was a concern.
In January 2006, a practical solution was set in motion by a staff nurse, a Certified Rehabilitation Registered Nurse®. The diabetic flow sheet format consisted of a table with blocks for documenting pertinent information (e.g., time of day, blood glucose level, who double checked the insulin).
The plan was to use a half-inch sticker for the cosign on the diabetic flow sheet. The nurse administering the insulin would bring a copy of the doctor’s orders, the insulin, and a sticker to another nurse who would double check the dose and sign the sticker. The sticker would then be placed on the diabetic flow sheet of the patient’s chart by the nurse administering the insulin.
The idea was presented to the unit managers, the rehabilitation clinical nurse specialists, and the policy and procedure committee of the medical center. With their endorsement, this change in the documentation practice was trialed.
In-depth staff education was accomplished prior to initiating the new method. Posters outlining the medical center’s policy for documenting insulin administration double checks and the use of the stickers were prepared for both nursing units (Figures 1, 2, and 3). The day the new procedure began, “STICK TO IT” signs were placed on the doors of the four medication rooms (Figure 4). The stickers and instructions for their use were placed on the medication refrigerator doors. A diabetic flow sheet with an example of sticker use was also provided.
Also adding to the ease of trial, it seemed the majority of the nurses welcomed new ideas to improve the efficiency of the documentation process and give them more time for direct patient care and teaching.
Prior to initiating the use of the stickers, a monitor of diabetic flow sheets revealed 187 administrations of insulin with 65 double checks documented.
Four weeks into using the stickers, a monitor of diabetic flow sheets discovered 230 administrations of insulin with documentation of 167 double checks. Although a few were documented directly by the nurses, the double checks were predominantly accomplished by using the stickers.
Documentation compliance climbed from 35% to 72%, and a fresh awareness of documenting insulin double checks was evident among the staff.
Many areas in the medical center have converted to computerized charting and the rehabilitation nurses can look forward to less handwritten documentation in the future. The sticker will become obsolete as the computerized medication administration documentation will allow for the nurses to document the double checks electronically. At present, the use of the sticker has been very effective in documenting compliance with the medical center’s policy for insulin administration.
About the Author
Margo Hospodar, RN CRRN, is a staff nurse at The Ohio State University Medical Center, Columbus, Ohio. Address correspondence to her to The Ohio State University Medical Center, Rehabilitation Nursing, Dodd Hall, 480 W. Medical Center Drive, Columbus, OH 43210 or firstname.lastname@example.org.
JCAHO’s 2004 Behavioral Health Care National Patient Safety Goals. (n.d.). Retrieved November 9, 2006, from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/04_bhc_npsgs.htm.