Reducing Treatment Errors Through Point-of-Care Glucometer Configuration
Published by Elsevier Inc..
BACKGROUND: Blood glucose (BG) testing is the most widely performed point-of-care (POC) test in a hospital setting. Multiple adverse events reported to the Food and Drug Administration (FDA) revealed that treatment decisions may be affected by information displayed on the POC glucometer's results screen. A randomized, crossover simulation study was conducted to compare two results screen configurations for ACCU-CHEK Inform II, a POC glucometer.
METHODS: Prior to the study, a heuristic evaluation of the results screen configurations and a pilot study were conducted to select the two results screen configurations for comparison. At two multicampus medical centers, 66 nurse participants experienced two computer-based simulation scenarios that asked them to interpret glucometer readings and make treatment decisions for simulated patients with 32 mg/dL BG levels and subtle symptoms of hypoglycemia. One scenario displayed a numeric value ("32 mg/dL"), and the other displayed a range abbreviation, such as "RR LO" (out of reportable range; low). Treatment errors were recorded when the participant did not treat the hypoglycemic patient with glucose or when they administered insulin.
RESULTS: When ACCU-CHEK Inform II displayed an "RR LO" reading, 10.6% of participants made a treatment error, including 6.7% of participants with prior training on the meaning of an "RR LO" reading. None of the participants made a treatment error when ACCU-CHEK Inform II displayed a "32 mg/dL" reading.
CONCLUSION: Displaying a numeric BG reading eliminated potentially life-threating treatment errors caused by confusing range abbreviations. Manufacturers should consider these findings during future research and development of POC glucometers.
| Medienart: |
E-Artikel |
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| Erscheinungsjahr: |
2018 |
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| Erschienen: |
2018 |
| Enthalten in: |
Zur Gesamtaufnahme - volume:44 |
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| Enthalten in: |
Joint Commission journal on quality and patient safety - 44(2018), 11 vom: 01. Nov., Seite 683-694 |
| Sprache: |
Englisch |
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| Beteiligte Personen: |
Estock, Jamie L [VerfasserIn] |
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| Links: |
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| Themen: |
Blood Glucose |
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| Anmerkungen: |
Date Completed 06.12.2019 Date Revised 17.12.2019 published: Print-Electronic Citation Status MEDLINE |
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| doi: |
10.1016/j.jcjq.2018.03.014 |
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| funding: |
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| Förderinstitution / Projekttitel: |
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| PPN (Katalog-ID): |
NLM287046974 |
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| 500 | |a Date Revised 17.12.2019 | ||
| 500 | |a published: Print-Electronic | ||
| 500 | |a Citation Status MEDLINE | ||
| 520 | |a Published by Elsevier Inc. | ||
| 520 | |a BACKGROUND: Blood glucose (BG) testing is the most widely performed point-of-care (POC) test in a hospital setting. Multiple adverse events reported to the Food and Drug Administration (FDA) revealed that treatment decisions may be affected by information displayed on the POC glucometer's results screen. A randomized, crossover simulation study was conducted to compare two results screen configurations for ACCU-CHEK Inform II, a POC glucometer | ||
| 520 | |a METHODS: Prior to the study, a heuristic evaluation of the results screen configurations and a pilot study were conducted to select the two results screen configurations for comparison. At two multicampus medical centers, 66 nurse participants experienced two computer-based simulation scenarios that asked them to interpret glucometer readings and make treatment decisions for simulated patients with 32 mg/dL BG levels and subtle symptoms of hypoglycemia. One scenario displayed a numeric value ("32 mg/dL"), and the other displayed a range abbreviation, such as "RR LO" (out of reportable range; low). Treatment errors were recorded when the participant did not treat the hypoglycemic patient with glucose or when they administered insulin | ||
| 520 | |a RESULTS: When ACCU-CHEK Inform II displayed an "RR LO" reading, 10.6% of participants made a treatment error, including 6.7% of participants with prior training on the meaning of an "RR LO" reading. None of the participants made a treatment error when ACCU-CHEK Inform II displayed a "32 mg/dL" reading | ||
| 520 | |a CONCLUSION: Displaying a numeric BG reading eliminated potentially life-threating treatment errors caused by confusing range abbreviations. Manufacturers should consider these findings during future research and development of POC glucometers | ||
| 650 | 4 | |a Journal Article | |
| 650 | 4 | |a Multicenter Study | |
| 650 | 4 | |a Randomized Controlled Trial | |
| 650 | 4 | |a Research Support, U.S. Gov't, Non-P.H.S. | |
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| 650 | 7 | |a Insulin |2 NLM | |
| 700 | 1 | |a Pham, Ivan-Thibault |e verfasserin |4 aut | |
| 700 | 1 | |a Curinga, Holly K |e verfasserin |4 aut | |
| 700 | 1 | |a Sprague, Benjamin J |e verfasserin |4 aut | |
| 700 | 1 | |a Boudreaux-Kelly, Monique Y |e verfasserin |4 aut | |
| 700 | 1 | |a Acevedo, Jeanette |e verfasserin |4 aut | |
| 700 | 1 | |a Jacobs, Katrina |e verfasserin |4 aut | |
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