JMIR Publications

ABSTRACT

Background:

Critically ill patients require constant point-of-care-testing (POCT) for blood glucose using glucometers to guide initiation and titration decisions of continuous insulin infusion. Transcribing blood glucose tests’ values from the glucometers into a paper log and the electronic medical record (EMR) is a very common yet error-prone practice in intensive care units (ICUs) given the lack of connectivity between glucometers and the EMR in many U.S. hospitals.

Objective:

This study examined (1) transcription errors of blood glucose values obtained by a glucometer and documented in the paper log and in the EMR vital signs flowsheet in a surgical trauma ICU, (2) insulin errors resulted from transcription errors of blood glucose values, (3) lack of documenting blood glucose values in the paper log and the EMR vital signs flowsheet, and (4) the average time for docking the glucometer.

Methods:

This secondary data analysis study examined 5049 point of care blood glucose tests for transcription errors, insulin errors, lack of documenting blood glucose values in the paper log and the EMR, and the glucometer docking time in a surgical trauma ICU. Transcription errors include errors in the paper log, errors in the EMR vital signs flowsheet, and errors in both. The results of the 5049 blood glucose tests were obtained from RALS®-Plus V1.5.1, a bi-directional interface software for in-hospital glucometers that uploads meters data after docking the meters into the EMR lab flowsheet. Chart audit was conducted to obtain the transcribed values of blood glucose tests from the EMR vital signs flowsheet and the patient demographic and clinical-related information. The paper log was accessed to obtain the corresponding transcribed values of the blood glucose tests. Three nurse educators obtained the data.

Results:

The 5049 blood glucose tests were pertinent to 234 patients. The total number of undocumented or untranscribed tests was 608 (12% out of 5049) in the paper log, 2064 (41% out of 5049) in the EMR vital signs flowsheet, and 239 (5% out of 5049) in both (paper log and the EMR vital signs flowsheet). The number of transcription errors for the documented tests was as follow: 98 (2% out of 4441 documented tests) in the paper log, 242 (8% out of 2985 tests) in the EMR vital signs flowsheet, and 43 (2% out of 2616 tests) in both. The percentage of transcription errors per patient was 0.4 (98 errors/234 patients) in the paper log, 1 (242 errors/234 patients) in the EMR vital signs flowsheet, and 0.2 in both (43/234 patients). Transcription errors in the paper log, the EMR vital signs flowsheet, and in both resulted in 8, 24, and 2 insulin errors, respectively. As a consequence, patients were given a lower or a high insulin dose than the dose they should receive if there were no transcription errors. Discrepancies in insulin doses were as follow: 2 units to 8 units lower insulin doses in the case of paper log transcription errors, 10 units lower to 3 units higher insulin doses in the case of transcription errors in the EMR vital signs flowsheet, and 2 units lower in the case of transcription errors in both. Overall, there were 30 unique insulin errors that affected 25 patients (11% out of 234 patients). The average time from the POCT to the time meters were docked (readings were uploaded into the EMR lab flowsheet) was 8 hours with a median of 5.5 hours. Some of the readings took 56 hours (2.3 days) to be uploaded into the EMR lab flowsheet.

Conclusions:

Transcription errors of blood glucose values obtained by glucometers do exist and result in insulin errors. A time lag exists between obtaining the results of blood glucose using glucometers and docking the meters to transfer the results into the lab flowsheet in the EMR. Given the high dependence on glucometers for POCT of blood glucose in ICUs, full EMR-glucometer interoperability is required for complete, accurate, and timely documentation of blood glucose values and elimination of transcription errors and the subsequent insulin-related errors in ICUs.