Hospitals often overlook the dangers of insulin: ISMP

After multiple nurses have been charged and imprisoned for administering fatal amounts of insulin, it's clear there's a lack of regulation in hospitals and nursing homes, the Winston-Salem Journal reported Nov. 16.

Reta Mays, CNA, is serving seven life sentences after a court found her guilty in 2021 of killing seven elderly veterans in West Virginia. She was not supposed to have access to the fatal doses of insulin, according to an Inspector General report. 

The next year, police charged Atrium Health Wake Forest Baptist Medical Center nurse Johnathan Hayes in connection to two patient deaths. He was "the top insulin dispenser, facility-wide, by seven times the average of the facility," police said. Atrium Health told Becker's at the time that it was "deeply saddened and concerned" by the situation, was working with law enforcement, and had conducted an in-depth analysis to ensure a similar event would not happen again.

Most recently, Heather Pressdee, RN, is accused of killing 17 patients in Pennsylvania nursing homes. The state's attorney general said the excessive insulin was administered on night shifts when staffing was sparse. 

For years, healthcare organizations have been advocating for stricter safeguards on insulin. In 2013, the American Society of Health-System Pharmacists published 10 recommendations for improving insulin safety in hospitals. The ASHP said it organized a 21-member panel because "insulin is frequently cited as one of the medications commonly implicated in medication errors in hospitals, and insulin-related medication errors have the potential to result in serious harm, including death."

The Institute for Safe Medication Practices' 2017 guideline on insulin says "subcutaneous insulin use [has] been overlooked and inadequately addressed" in hospitals and other healthcare facilities. 

CMS lists insulin as a "time-critical" medication and requires hospitals to track the name of the patient; the date, time and size of the dosage; the type of insulin; and the signature of the person who administered the drug, according to the Winston-Salem Journal. Plus, hospitals can go into immediate jeopardy if CMS finds serious patient safety concerns. 

But there are no federal rules on insulin doses receiving bar codes, and insulin is on a lower priority than opioids, the Journal reported. 

"Insulin isn't addictive or recreationally abused, but it is dangerous," Tony O'Dell, a West Virginia lawyer who represented 10 families of Ms. Mays' victims, told the Journal.

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