- Email: [email protected]
or health care providers
Diuhetu
Rrvecwch uud Clirricul
Suppl. (I 988) 3540
Pructiw,
35
Elsevier
DRC SOI IO
Insulin injections: mistakes and errors made by patients and/or health care providers Monique
KeJ, I~YUY~:Patient
education;
Kreinhofer,
Health
Marion
care professionals’
Aufseesser-Stein
awareness:
Introduction
Complex injection procedures are usually recommended for insulin-treated patients. Traditionally, patients on insulin have been instructed to use ‘aseptic technique’ precautions against infection at the injection site [1.2]. However, there is a growing trend towards simplification, without added risk for the patient. In a recent article Borders et al. [3] showed that non-compliance with complex insulin injection procedures is commonplace. They further suggested that modification of traditional teaching methods may result in financial savings, improved patient self-care success and enhanced health care provider credibility. The diabetic patient learning to inject insulin has to acquire several skills, and numerous mistakes may be made in teaching them. This chapter describes those that occur frequently among patients and/or health care professionals. Avoidance of ‘obAddress
for correspondence:
Marion
chologist. Monique Kreinhofer. RN. Medical Director. Diabetes Treatment WHO Collaborating betes Education.
Aufseesser-Stein,
Center for Reference University
Cantonal
and Research
Hospital.
I21
in Dia-
I Geneva 4.
Switzerland.
Olh8-8327’88/$03.50
Psy-
or Jean Philippe Assal, and Teaching Unit and
X: 1988 Elsevier Science Publishers
Mastering
and Jean Philippe
safe and simple injection
Assal
technique
vious’ pitfalls and simplification of injection technique may help improve compliance with the requirements for safe and accurate injection technique.
Patients’ errors versus health (HCPs) mistakes
care
professionals’
Patients’ errors often result from ignorance. forgetfulness (&Ididn’t know’, ‘I forgot that’) and/or misunderstanding (‘I didn’t realize the consequence would be .‘). Health care professionals’ mistakes usually result from underestimation of the complexity of the task that they are teaching. An injection is such a routine procedure for HCPs that the different steps involved in the process seem self-evident. They should, however, bear in mind that learning self-injection is technically and emotionally demanding for the novice insulin user, who must grasp each successive step in the injection process. Beginnings are always difficult and give rise to anxiety; time is always needed to master the different steps involved, whether the technique to be learned be driving a car, wind-surfing or insulin injection.
B.V. (Biomedical
Division)
36
Insulin injections: key situations/actions 1. Choice of material - Disposable syringe -- Clear graduation - Preferable incorporated needle - One concentration per syringe - Importance of checking material 2. Time schedule - Fix injection and meal times
with patient before starting insulin 3. Setting ~ Handwashing
Mistakes and attitudes of patient
Mistakes and attitudes of doctor/nurse
- Does not know type of syringe used - Cannot ensure that prescription is correctly renewed
- Syringe prescription too vague - Does not inform patient well about syringe make, graduation, etc. - Does not check if material corresponds to prescription
~ Does not bring injection material to consultation
- Does not understand importance of meal and injection times
- Neglects patient’s usual timetable when planning new one
- Fails to wash hands before injection
~ Gives unnecessarily complicated instructions for hand asepsis - Does not make patient comfortable ~ Unaware that patients misread due to light conditions. Believes patient is incapable of taking correct dose - Unaware that patient wears glasses at all, or should be wearing them
- Patient’s position
- Cannot decide to sit or stand
~ Light conditions
- Does not realize need for good light (graduation, bubbles)
- Glasses
- Forgets to wear glasses. Does not bring glasses to consultation
4. Filling a syringe - Insulin vial
- Filling a syringe
- Draw up additional insulin to leave margin for elimination of air bubbles at plunger or needle end
~ Does not shake vial - Injects supernatant when vial is full and concentrated insulin when it is nearly empty - Does not express fear or incomprehension about injection - Does not draw up additional insulin to eliminate air bubbles
- Automatically shakes vial without explaining why, or facilitating patient’s own discovery of why vial should be shaken before filling syringe - Believes job is done once he/she has demonstrated syringe filling - Fails to explain that elimination technique depends on bubbles at plunger or needle end
37
Mistakes
Insulin injections: key situations/actions Needle in insulin
- Air in vial
- New/partly
- A badly fixed needle leads to a loss of insulin during injection
sites
- One anatomical region change site daily
6. Injection technique - Grip skin between two fingers - Inject insulin
Mistakes
of
and attitudes
doctor/nurse
- Holds vial at inappropriate
- Does not practise
of
with almost
angle without realizing he is only drawing air, or needle is beyond insulin when vial is
empty vial/check patient’s filling technique. Poor control misattributed to non-obser-
almost empty - Unaware that part of the insulin returns to vial in case of partial vacuum
vance of diet may result - Unaware of patient’s incorrect doses - Increases/decreases dose to prevent unexplained hyperi hypoglycemia - Does not teach patient to observe vial capsule for too much/little air in vial
~ Unaware of problem. Even if patient is aware of concave/ convex capsule, unable to draw conclusions - Unaware of difference between new and partly used vial
used vial
5. Injection sites - Suggest easily accessible
and attitudes
patient
- Injects additional insulin ning risk of hypoglycemia
run-
- Hesitates
site
about
injection
~ Changes region and site daily or injects into the same site because this is less painful
- Does not let go of skin after introducing needle _ Injects insulin superficially, which is often very painful
- Usually practises with new vials. Does not observe and correct patient’s using new/ partly used vial - Preferably chooses sealed needles. Instruct patient what to do if insulin escapes
- Often suggests arms and forgets patient will only have one free hand. Thigh is preferable. (Do not leave patient too much choice when starting injections) - Does not explain clearly why region should be constant but site varied
- Unaware of these mistakes - Does not check patient’s skin for induration
38 Insulin
Mistakes
injections:
and attitudes
of
Mistakes
patient
key situations/actions
and attitudes
of
doctor/nurse -
7. Role of snacks/prevention _ Peak: day and night
of hypoglycemia ~ Unaware Cannot
_ Patient’s
habits
of insulin evaluate
hypoglycemia ~ Not accustomed
action.
risk of to snacks
_ Does not explain
~ Often unfamiliar patient’s
_ Insulin
action/snacks
_ Importance
of snacks
~ Choice
of snacks
~ Always
have sugar on you
Choice
of food to treat hypos
8. Special situations Traveling ! - Knowledge about insulin concentration (40, 80. 100 U)
- Changing
- Buying
time zone
insulin/syringe
_ Does not understand relation between insulin and snacks _ Does not see need for snacks ~ Forgets them ~ Embarassed to take snack (work, etc.) _ Unfamiliar with different possibilities ~ Does not know what a hypo is ~ Thinks he will have enough time to fetch sugar in case of hypo _ Afraid to take sweets, fruit, fruit juice or coke as NIDDMs are ‘drilled’ not to
~ Forgets etc.
about
theft, damage,
Abandons idea of travel for fear of inability to cope May buy insulin which does not correspond to the syringe
insulin
ac-
tion clearly and simply
pre-insulin
with dietary
habits ~ Does not explain relationship between insulin action and snacks - Does not suggest practical solutions (reminders; snacks easy to take, etc.) - Unaware of patient’s knowledge concerning standardized 15-30-g carbohydrate snacks ~ Does not ask patient to describe hypo symptoms _ Does not ask patient if and how much sugar he has on him at consultation _ Does not insist enough on special situation of hypo. Important to teach patient to choose suitable snacks to compensate
- Explains difference in volume but does not let patient discover difference visually, leaving him to calculate the volume _ Does not realize that patient has not been on vacation due to diabetes
39
Mistakes
Insulin injections: key situations/actions
~ Continue
insulin
and attitudes
of
- Stops insulin because
and attitudes
of
doctor/nurse
patient
when ill
Mistakes
(fear of hypos
not hungry)
_ Does not insist that insulin must be continued.
Does not
tell what to eat and drink when ill (sugared tea, juice, oatmeal, Elderly putients Techniyur ~ Magnifying glass, tutor,
- Unnecessary
~ Does not suggest technical aides but jumps to conclusion that patient cannot inject himself _ Insists on unnecessarily tech-
etc.
steps
etc.)
- Confused
nical methods Lifestyle _ Time schedule,
food, free
time. etc.
_ Some patients have difficulty ‘getting going’ in the morning
~ Does not take patient’s former lifestyle into consideration and imposes new lifestyle (irregular/poor meals) _ Should take more time for elderly patients --
Insulin injections in type 2 diabetes
dent diabetics (IDDs), NIDDM patients often do not ‘feel’ their diabetes (no uncomfortable symp-
Insulin treatment not only involves daily injections but also regular urine or blood sugar tests. a fixed time schedule, regular carbohydrate intake at mealtimes and snacks. Non-insulin-dependent diabetes (NIDDM) patients have often been on dietary treatment, with or without oral agents, for months or even years before being put on insulin. They are bound to react to the announcement that insulin is required. Using the ‘Stages of Acceptance’ [4] we have observed that non-insulin-treated patients tend to deny the existence of their illness and consider diabetes synonymous with insulin treatment. The attitude of denial is facilitated by the fact that. unlike insulin-depen-
toms). The first injection is a source of great all diabetics. The quicker it is performed Each patient will differ in the time and quired to overcome his initial anxiety ready to learn in greater detail how to various aspects of insulin injection.
anxiety to the better. support reand to be master the
Mistakes made by patients and/or health care professionals We have chosen a limited number where patient and/or health care
of situations professionals
40
often make mistakes, and have given ‘hints’, where appropriate, on how to avoid them. Mistakes will vary with patient age, dexterity, eyesight, degree of acceptance of the disease, injection training, and many other factors. It is beyond the scope of this article to provide an exhaustive list of guidelines. Each health care professional should adapt it to patients’ specific needs. Conclusions
Going onto insulin involves far-reaching changes in the daily life of the diabetic patient. The difficulty of this task is undisputed. Modifying a patient’s lifestyle may be the greatest challenge to those engaged in patient education. Teaching the NIDDM patient to manage insulin is arduous. It requires patience and perseverance on the part of both patient and health care providers. In order to ensure the success of insulin treatment it should be made as safe and easy as possible for the patient. Avoiding unnecessarily complex techniques and adapting the treatment strategy to each patient’s needs should help improve patient compliance. Systematic studies evaluating different forms of injection training are required in order to improve the efficiency of patient education.
Suggested reading ~ Assal, J.Ph. and Liniger, C. (Eds.) (1985, 1986)
Teaching Letters. Diabetes Education Study Group of the European Association for the Study of Diabetes. Copies from Dr. Nunes-Correa, Secretary, DESG, rua Nova Do Almada 114d, 1200 Lisbon, Portugal (in English, French, Greek, Italian, Spanish). - Becker, M.H. (1974) The health belief model and personal behaviour. Health Educ. Monogr. 2. ~ Gagne, R.M. (1975) Essentials of Learning for Instruction. Dryden Press, Montreal.
References Krall, L.P. (Ed.) (1978) Joslin Diabetes Manual, I Ith edn. Lea and Febiger, Philadelphia, PA, pp. 91-95. Blevins, D.R. (1979) The Diabetic and Nursing Care, McGraw-Hill, New York, pp. 2488249. Borders, L.M. et al. (1984) Traditional insulin-use practices and bacterial contamination. Diabetes Care 7, 121~127. Assal, J.Ph. et al. (1984) Developmental stages of patient acceptance in diabetes. In: J.Ph. Assal et al. (Eds.), Diabetes Education, Excerpta Medica International Congress Series No. 624. Excerpta Medica, Amsterdam, pp. 207-219.
Rrvecwch uud Clirricul
Suppl. (I 988) 3540
Pructiw,
35
Elsevier
DRC SOI IO
Insulin injections: mistakes and errors made by patients and/or health care providers Monique
KeJ, I~YUY~:Patient
education;
Kreinhofer,
Health
Marion
care professionals’
Aufseesser-Stein
awareness:
Introduction
Complex injection procedures are usually recommended for insulin-treated patients. Traditionally, patients on insulin have been instructed to use ‘aseptic technique’ precautions against infection at the injection site [1.2]. However, there is a growing trend towards simplification, without added risk for the patient. In a recent article Borders et al. [3] showed that non-compliance with complex insulin injection procedures is commonplace. They further suggested that modification of traditional teaching methods may result in financial savings, improved patient self-care success and enhanced health care provider credibility. The diabetic patient learning to inject insulin has to acquire several skills, and numerous mistakes may be made in teaching them. This chapter describes those that occur frequently among patients and/or health care professionals. Avoidance of ‘obAddress
for correspondence:
Marion
chologist. Monique Kreinhofer. RN. Medical Director. Diabetes Treatment WHO Collaborating betes Education.
Aufseesser-Stein,
Center for Reference University
Cantonal
and Research
Hospital.
I21
in Dia-
I Geneva 4.
Switzerland.
Olh8-8327’88/$03.50
Psy-
or Jean Philippe Assal, and Teaching Unit and
X: 1988 Elsevier Science Publishers
Mastering
and Jean Philippe
safe and simple injection
Assal
technique
vious’ pitfalls and simplification of injection technique may help improve compliance with the requirements for safe and accurate injection technique.
Patients’ errors versus health (HCPs) mistakes
care
professionals’
Patients’ errors often result from ignorance. forgetfulness (&Ididn’t know’, ‘I forgot that’) and/or misunderstanding (‘I didn’t realize the consequence would be .‘). Health care professionals’ mistakes usually result from underestimation of the complexity of the task that they are teaching. An injection is such a routine procedure for HCPs that the different steps involved in the process seem self-evident. They should, however, bear in mind that learning self-injection is technically and emotionally demanding for the novice insulin user, who must grasp each successive step in the injection process. Beginnings are always difficult and give rise to anxiety; time is always needed to master the different steps involved, whether the technique to be learned be driving a car, wind-surfing or insulin injection.
B.V. (Biomedical
Division)
36
Insulin injections: key situations/actions 1. Choice of material - Disposable syringe -- Clear graduation - Preferable incorporated needle - One concentration per syringe - Importance of checking material 2. Time schedule - Fix injection and meal times
with patient before starting insulin 3. Setting ~ Handwashing
Mistakes and attitudes of patient
Mistakes and attitudes of doctor/nurse
- Does not know type of syringe used - Cannot ensure that prescription is correctly renewed
- Syringe prescription too vague - Does not inform patient well about syringe make, graduation, etc. - Does not check if material corresponds to prescription
~ Does not bring injection material to consultation
- Does not understand importance of meal and injection times
- Neglects patient’s usual timetable when planning new one
- Fails to wash hands before injection
~ Gives unnecessarily complicated instructions for hand asepsis - Does not make patient comfortable ~ Unaware that patients misread due to light conditions. Believes patient is incapable of taking correct dose - Unaware that patient wears glasses at all, or should be wearing them
- Patient’s position
- Cannot decide to sit or stand
~ Light conditions
- Does not realize need for good light (graduation, bubbles)
- Glasses
- Forgets to wear glasses. Does not bring glasses to consultation
4. Filling a syringe - Insulin vial
- Filling a syringe
- Draw up additional insulin to leave margin for elimination of air bubbles at plunger or needle end
~ Does not shake vial - Injects supernatant when vial is full and concentrated insulin when it is nearly empty - Does not express fear or incomprehension about injection - Does not draw up additional insulin to eliminate air bubbles
- Automatically shakes vial without explaining why, or facilitating patient’s own discovery of why vial should be shaken before filling syringe - Believes job is done once he/she has demonstrated syringe filling - Fails to explain that elimination technique depends on bubbles at plunger or needle end
37
Mistakes
Insulin injections: key situations/actions Needle in insulin
- Air in vial
- New/partly
- A badly fixed needle leads to a loss of insulin during injection
sites
- One anatomical region change site daily
6. Injection technique - Grip skin between two fingers - Inject insulin
Mistakes
of
and attitudes
doctor/nurse
- Holds vial at inappropriate
- Does not practise
of
with almost
angle without realizing he is only drawing air, or needle is beyond insulin when vial is
empty vial/check patient’s filling technique. Poor control misattributed to non-obser-
almost empty - Unaware that part of the insulin returns to vial in case of partial vacuum
vance of diet may result - Unaware of patient’s incorrect doses - Increases/decreases dose to prevent unexplained hyperi hypoglycemia - Does not teach patient to observe vial capsule for too much/little air in vial
~ Unaware of problem. Even if patient is aware of concave/ convex capsule, unable to draw conclusions - Unaware of difference between new and partly used vial
used vial
5. Injection sites - Suggest easily accessible
and attitudes
patient
- Injects additional insulin ning risk of hypoglycemia
run-
- Hesitates
site
about
injection
~ Changes region and site daily or injects into the same site because this is less painful
- Does not let go of skin after introducing needle _ Injects insulin superficially, which is often very painful
- Usually practises with new vials. Does not observe and correct patient’s using new/ partly used vial - Preferably chooses sealed needles. Instruct patient what to do if insulin escapes
- Often suggests arms and forgets patient will only have one free hand. Thigh is preferable. (Do not leave patient too much choice when starting injections) - Does not explain clearly why region should be constant but site varied
- Unaware of these mistakes - Does not check patient’s skin for induration
38 Insulin
Mistakes
injections:
and attitudes
of
Mistakes
patient
key situations/actions
and attitudes
of
doctor/nurse -
7. Role of snacks/prevention _ Peak: day and night
of hypoglycemia ~ Unaware Cannot
_ Patient’s
habits
of insulin evaluate
hypoglycemia ~ Not accustomed
action.
risk of to snacks
_ Does not explain
~ Often unfamiliar patient’s
_ Insulin
action/snacks
_ Importance
of snacks
~ Choice
of snacks
~ Always
have sugar on you
Choice
of food to treat hypos
8. Special situations Traveling ! - Knowledge about insulin concentration (40, 80. 100 U)
- Changing
- Buying
time zone
insulin/syringe
_ Does not understand relation between insulin and snacks _ Does not see need for snacks ~ Forgets them ~ Embarassed to take snack (work, etc.) _ Unfamiliar with different possibilities ~ Does not know what a hypo is ~ Thinks he will have enough time to fetch sugar in case of hypo _ Afraid to take sweets, fruit, fruit juice or coke as NIDDMs are ‘drilled’ not to
~ Forgets etc.
about
theft, damage,
Abandons idea of travel for fear of inability to cope May buy insulin which does not correspond to the syringe
insulin
ac-
tion clearly and simply
pre-insulin
with dietary
habits ~ Does not explain relationship between insulin action and snacks - Does not suggest practical solutions (reminders; snacks easy to take, etc.) - Unaware of patient’s knowledge concerning standardized 15-30-g carbohydrate snacks ~ Does not ask patient to describe hypo symptoms _ Does not ask patient if and how much sugar he has on him at consultation _ Does not insist enough on special situation of hypo. Important to teach patient to choose suitable snacks to compensate
- Explains difference in volume but does not let patient discover difference visually, leaving him to calculate the volume _ Does not realize that patient has not been on vacation due to diabetes
39
Mistakes
Insulin injections: key situations/actions
~ Continue
insulin
and attitudes
of
- Stops insulin because
and attitudes
of
doctor/nurse
patient
when ill
Mistakes
(fear of hypos
not hungry)
_ Does not insist that insulin must be continued.
Does not
tell what to eat and drink when ill (sugared tea, juice, oatmeal, Elderly putients Techniyur ~ Magnifying glass, tutor,
- Unnecessary
~ Does not suggest technical aides but jumps to conclusion that patient cannot inject himself _ Insists on unnecessarily tech-
etc.
steps
etc.)
- Confused
nical methods Lifestyle _ Time schedule,
food, free
time. etc.
_ Some patients have difficulty ‘getting going’ in the morning
~ Does not take patient’s former lifestyle into consideration and imposes new lifestyle (irregular/poor meals) _ Should take more time for elderly patients --
Insulin injections in type 2 diabetes
dent diabetics (IDDs), NIDDM patients often do not ‘feel’ their diabetes (no uncomfortable symp-
Insulin treatment not only involves daily injections but also regular urine or blood sugar tests. a fixed time schedule, regular carbohydrate intake at mealtimes and snacks. Non-insulin-dependent diabetes (NIDDM) patients have often been on dietary treatment, with or without oral agents, for months or even years before being put on insulin. They are bound to react to the announcement that insulin is required. Using the ‘Stages of Acceptance’ [4] we have observed that non-insulin-treated patients tend to deny the existence of their illness and consider diabetes synonymous with insulin treatment. The attitude of denial is facilitated by the fact that. unlike insulin-depen-
toms). The first injection is a source of great all diabetics. The quicker it is performed Each patient will differ in the time and quired to overcome his initial anxiety ready to learn in greater detail how to various aspects of insulin injection.
anxiety to the better. support reand to be master the
Mistakes made by patients and/or health care professionals We have chosen a limited number where patient and/or health care
of situations professionals
40
often make mistakes, and have given ‘hints’, where appropriate, on how to avoid them. Mistakes will vary with patient age, dexterity, eyesight, degree of acceptance of the disease, injection training, and many other factors. It is beyond the scope of this article to provide an exhaustive list of guidelines. Each health care professional should adapt it to patients’ specific needs. Conclusions
Going onto insulin involves far-reaching changes in the daily life of the diabetic patient. The difficulty of this task is undisputed. Modifying a patient’s lifestyle may be the greatest challenge to those engaged in patient education. Teaching the NIDDM patient to manage insulin is arduous. It requires patience and perseverance on the part of both patient and health care providers. In order to ensure the success of insulin treatment it should be made as safe and easy as possible for the patient. Avoiding unnecessarily complex techniques and adapting the treatment strategy to each patient’s needs should help improve patient compliance. Systematic studies evaluating different forms of injection training are required in order to improve the efficiency of patient education.
Suggested reading ~ Assal, J.Ph. and Liniger, C. (Eds.) (1985, 1986)
Teaching Letters. Diabetes Education Study Group of the European Association for the Study of Diabetes. Copies from Dr. Nunes-Correa, Secretary, DESG, rua Nova Do Almada 114d, 1200 Lisbon, Portugal (in English, French, Greek, Italian, Spanish). - Becker, M.H. (1974) The health belief model and personal behaviour. Health Educ. Monogr. 2. ~ Gagne, R.M. (1975) Essentials of Learning for Instruction. Dryden Press, Montreal.
References Krall, L.P. (Ed.) (1978) Joslin Diabetes Manual, I Ith edn. Lea and Febiger, Philadelphia, PA, pp. 91-95. Blevins, D.R. (1979) The Diabetic and Nursing Care, McGraw-Hill, New York, pp. 2488249. Borders, L.M. et al. (1984) Traditional insulin-use practices and bacterial contamination. Diabetes Care 7, 121~127. Assal, J.Ph. et al. (1984) Developmental stages of patient acceptance in diabetes. In: J.Ph. Assal et al. (Eds.), Diabetes Education, Excerpta Medica International Congress Series No. 624. Excerpta Medica, Amsterdam, pp. 207-219.