INSULIN-RELATED MEDICATION ERRORS AND CONTRIBUTING
FACTORS AT KENYATTA NATIONAL HOSPITAL
BY - AYWAK DOROTHY ATIENO
U51/70246/2013
M.PHARM (EPIVIGIL) - 2015
ABSTRACT
Introduction: Insulin is used in the management of hyperglycemia attributed to diabetes, a
chronic illness with a prevalence of 4.7% in Kenyan adults. Insulin has a narrow therapeutic
index and is ranked among the top 5 “high alert” medications by the Institute of Safe Medication
Practices. High alert medications bear a significant risk of patient harm including death when
used inappropriately. Insulin related medication errors can occur at any stage of medicine use
process from prescribing, dispensing, administration to monitoring of therapy. Medication errors
affect the quality of care by contributing to poor patient outcomes hence patient safety is a prime
target for healthcare improvement. Pharmacists play a key role in ensuring the provision of safe
medication management systems in order to reduce the risk to patients. Studies done at Kenyatta
National Hospital (KNH) have mainly focused on medication errors in general. However, none
has highlighted the frequency of insulin related medication errors. These errors are important as
they contribute to increased morbidity and mortality especially among the diabetic population.
Objective: This study aims at determining the prevalence of insulin related medication errors
and contributing factors in KNH.
Methodology: The study will consist of two parts. The quantitative part aims at determining the
prevalence of insulin-related medication errors and the associated risk factors. The second part is
qualitative and will explore gaps in patient safety system and identify possible interventions to
mitigate the occurrence of insulin related medication errors. Descriptive statistics will be used to
explore demographic factors such as age, gender and also estimate the prevalence of insulin
related medication errors in the data set. Logistic regression will be used to compare medication
errors with patient and structure related factors. Thematic analysis of qualitative data will be
carried out.
Expected Outcomes: The study will highlight the magnitude of insulin related errors and the
contributing factors. This will aid in defining a set of actions to minimize medication errors and
promote safe use of insulin. The findings of the study will be disseminated to the Pharmacy and
Medicine departments among other clinical departments of KNH. The findings will also be
published in an open access peer reviewed journal and generate topics for continuous
professional development.