A total number of 4,003 pharmacist interventions were identified over the 8-month study period. Following data cleaning, 3,975 interventions were identified and included in the analysis.
Interventions And Insulin Brands
Sixteen insulin brands were involved in 3,907 (98.29%) interventions (no insulin brand recorded against 68, 1.71%, of the interventions). A comparison of intervention and ordering data (Table 1) showed that the highest percentage of interventions (46.44%) were for Lantus® whereas this brand made up 21.90% of the insulin orders over the study period. NovoRapid® was the insulin mostly ordered at 58.43% and contributed 23.85% towards the interventions.
Table 1
Interventions and orders per insulin brand
Insulin by brand
|
No. interventions
|
% interventions
|
No. orders
|
% orders
|
Lantus®
|
1,846
|
46.44%
|
21,706
|
21.90%
|
NovoRapid®
|
948
|
23.85%
|
57,926
|
58.43%
|
NovoMix 30/70®
|
517
|
13.01%
|
6,877
|
6.94%
|
Protaphane®
|
129
|
3.25%
|
2,280
|
2.30%
|
Ryzodeg 70/30®
|
115
|
2.89%
|
1,358
|
1.37%
|
Levemir®
|
89
|
2.24%
|
1,812
|
1.83%
|
Toujeo®
|
70
|
1.76%
|
873
|
0.88%
|
#Not recorded
|
68
|
1.71%
|
0
|
-
|
Humalog®
|
51
|
1.28%
|
1,659
|
1.67%
|
Mixtard 30/70®
|
48
|
1.21%
|
660
|
0.67%
|
Actrapid®
|
31
|
0.78%
|
2,228
|
2.25%
|
Apidra®
|
27
|
0.68%
|
1,235
|
1.25%
|
Humulin 30/70®
|
25
|
0.63%
|
284
|
0.29%
|
Humalog Mix 25/75®
|
6
|
0.15%
|
83
|
0.08%
|
Humulin NPH®
|
4
|
0.10%
|
44
|
0.04%
|
Humulin R®
|
1
|
0.03%
|
52
|
0.05%
|
U200 Humalog®
|
0
|
-
|
20
|
0.02%
|
Fiasp®
|
0
|
-
|
18
|
0.02%
|
Humalog Mix 50/50®
|
0
|
-
|
12
|
0.01%
|
Mixtard 50/50®
|
0
|
-
|
2
|
0.00%
|
TOTAL
|
3,975
|
100.00%
|
99,129
|
100.00%
|
#Insulin brand not recorded however intervention was related to insulin |
Pharmacists Recording Of Interventions
The majority of interventions (3,356, 84.43%), were recorded by HRM pharmacists (Fig. 1). July and August 2019 had the highest numbers of interventions with 628 and 643 (15.80% and 16.18%) interventions respectively. The rolling average shows a modest increase in HRM pharmacist interventions in January 2020 compared to the previous four months. The recording of HRM pharmacist interventions was relatively low in June 2019, which was when the position was created.
Intervention Type
Interventions were categorised as either medicine optimisation or prescribing error interventions and the type of insulin: ultra short-acting, short-acting, long-acting and mixed (Table 2).
Table 2
Types of insulin matched to frequency of intervention categories
Intervention Category/
Type of insulin
|
Ultra short-acting (%)
|
Short-acting
(%)
|
Long-acting
(%)
|
Mixed
(%)
|
Not recorded
(%)
|
Total Interventions
(%)
|
Medicine optimisation
|
|
|
#Future doses not charted
|
666
|
(16.75%)
|
17
|
(0.43%)
|
1,701
|
(42.79%)
|
549
|
(13.81%)
|
52
|
(1.31%)
|
2,985
|
(75.09%)
|
Optimisation of dosing regimen
|
184
|
(4.63%)
|
7
|
(0.18%)
|
134
|
(3.37%)
|
76
|
(1.91%)
|
12
|
(0.30%)
|
413
|
(10.39%)
|
*LAM conversion
|
0
|
(0.00%)
|
0
|
(0.00%)
|
5
|
(0.13%)
|
4
|
(0.10%)
|
0
|
(0.00%)
|
9
|
(0.23%)
|
TOTAL
|
|
|
|
|
|
|
|
|
|
|
3,407
|
(85.71%)
|
Prescribing errors
|
|
|
Duplicate order
|
59
|
(1.48%)
|
0
|
(0.00%)
|
82
|
(2.06%)
|
15
|
(0.38%)
|
1
|
(0.03%)
|
157
|
(3.95%)
|
Weekly order recurring
|
9
|
(0.23%)
|
0
|
(0.00%)
|
46
|
(1.16%)
|
11
|
(0.28%)
|
0
|
(0.00%)
|
66
|
(1.66%)
|
Incorrect dose
|
18
|
(0.45%)
|
0
|
(0.00%)
|
36
|
(0.91%)
|
9
|
(0.23%)
|
0
|
(0.00%)
|
63
|
(1.58%)
|
Day of the week outside of date range
|
8
|
(0.20%)
|
0
|
(0.00%)
|
38
|
(0.96%)
|
11
|
(0.28%)
|
0
|
(0.00%)
|
57
|
(1.43%)
|
Missed dose
|
13
|
(0.33%)
|
0
|
(0.00%)
|
32
|
(0.81%)
|
11
|
(0.28%)
|
0
|
(0.00%)
|
56
|
(1.41%)
|
Instructions unclear
|
31
|
(0.78%)
|
2
|
(0.05%)
|
20
|
(0.50%)
|
4
|
(0.10%)
|
2
|
(0.05%)
|
56
|
(1.41%)
|
$Dose charted in advance
|
8
|
(0.20%)
|
2
|
(0.05%)
|
20
|
(0.50%)
|
9
|
(0.23%)
|
0
|
(0.00%)
|
39
|
(0.98%)
|
Unsafe order
|
7
|
(0.18%)
|
0
|
(0.00%)
|
12
|
(0.30%)
|
3
|
(0.08%)
|
0
|
(0.00%)
|
22
|
(0.55%)
|
Incorrect frequency
|
6
|
(0.15%)
|
0
|
(0.00%)
|
6
|
(0.15%)
|
8
|
(0.20%)
|
0
|
(0.00%)
|
20
|
(0.50%)
|
No valid medicine indication
|
13
|
(0.33%)
|
4
|
(0.10%)
|
1
|
(0.03%)
|
0
|
(0.00%)
|
0
|
(0.00%)
|
18
|
(0.45%)
|
Not receiving a medicine for condition
|
4
|
(0.10%)
|
0
|
(0.00%)
|
5
|
(0.13%)
|
1
|
(0.03%)
|
1
|
(0.03%)
|
11
|
(0.28%)
|
TOTAL
|
|
|
|
|
|
|
|
|
|
|
568
|
(14.29%)
|
# Future doses not charted: The absence of an order(s) for upcoming doses of insulin e.g. for the next meal time or coming days |
* LAM: List of approved medicines |
$ Dose charted in advance: A pre-order(s) for an upcoming dose of insulin e.g. at next meal time or coming days without considering patient’s clinical presentation |
Medicine optimisation interventions involved pre-emptive recommendations to prevent medicine errors from occurring, as well as improving patient outcomes by using medicines more effectively (e.g. ensuring insulin was ordered in advance where appropriate, suggesting dose adjustments based on recorded BGLs, recommending alternative insulin regimes when patient's own was unavailable). Prescribing error interventions involved corrective actions undertaken by pharmacists in response to an error in prescribing, in order to prevent patient harm (e.g. duplicate orders prescribed for the same medicine, incorrect doses prescribed, missed doses of insulin, doses charted for the incorrect date range, doses charted a week in advance).
Most interventions (3,407, 85.71%) were classified as medicine optimisation and 568 (14.29%) as prescribing errors. In the medicine optimisation intervention category, 75.09% (2,985) were due to ‘Regular medication not charted’, where the pharmacist alerted the prescriber pre-emptively to chart an upcoming insulin dose to prevent the dose from being missed. ‘Regular medication not charted’ mainly involved long-acting insulins (42.79%). Of the interventions classified as prescribing errors, 157 (3.95%) were due to a duplicate order.