this performance improvement study used a one - group pre- and postintervention design at an academic 150-bed children 's hospital from february 2006 to january 2008 . the pediatric nursing staff ( see supplemental table 1 for demographics , available in an online appendix at http://care.diabetesjournals.org/cgi/content/full/dc10-0031/dc1 ) was required to complete a three - part module ( view at http://rushakoff.com/rushakoff/rushakoff2 ) . section one provides information regarding types of diabetes , insulin pharmacokinetics , physiological insulin dosing , calculating and administering a diluted insulin dose , recognition and management of hypoglycemia , and insulin pump therapy and explains our institution 's two - rn independent check process for high - alert medications ( two rns independently determine insulin dose from physician order ) . section two provides information regarding use of the pediatric subcutaneous insulin order set , including timing of injections and glucose monitoring . section three consists of 15 questions related to interpreting insulin orders , determining the correct insulin dose , and identifying nursing actions based on the blood glucose and carbohydrate amount . for each question , if answered incorrectly , the nurse was instructed why the selected answer was incorrect and was required to try again . this analytic sample consisted of all pediatric patients during the study periods with a diagnosis of diabetes or hyperglycemia . all eligible charts were reviewed by two members of the study team ( m.m.s . and c.r.o . ) to identify the number of possible and actual insulin - related medication errors . using a comprehensive audit tool ( supplemental table 2 ) created by the research team , retrospective chart audits were conducted for a period of 6 months before implementing the module and 26 months postimplementation . opportunity for error was defined as each time the blood glucose should have been checked per physician order or the hypoglycemia protocol . an error was defined as any dose of insulin given or omitted that deviated from the physician order ( omission of an insulin dose , wrong insulin dose or type , wrong administration time , blood glucose not checked per order or hypoglycemia protocol , and blood glucose not documented in the record ) . the pediatric nursing staff ( see supplemental table 1 for demographics , available in an online appendix at http://care.diabetesjournals.org/cgi/content/full/dc10-0031/dc1 ) was required to complete a three - part module ( view at http://rushakoff.com/rushakoff/rushakoff2 ) . section one provides information regarding types of diabetes , insulin pharmacokinetics , physiological insulin dosing , calculating and administering a diluted insulin dose , recognition and management of hypoglycemia , and insulin pump therapy and explains our institution 's two - rn independent check process for high - alert medications ( two rns independently determine insulin dose from physician order ) . section two provides information regarding use of the pediatric subcutaneous insulin order set , including timing of injections and glucose monitoring . section three consists of 15 questions related to interpreting insulin orders , determining the correct insulin dose , and identifying nursing actions based on the blood glucose and carbohydrate amount . for each question , if answered incorrectly , the nurse was instructed why the selected answer was incorrect and was required to try again . this analytic sample consisted of all pediatric patients during the study periods with a diagnosis of diabetes or hyperglycemia . all eligible charts were reviewed by two members of the study team ( m.m.s . and c.r.o . using a comprehensive audit tool ( supplemental table 2 ) created by the research team , retrospective chart audits were conducted for a period of 6 months before implementing the module and 26 months postimplementation . opportunity for error was defined as each time the blood glucose should have been checked per physician order or the hypoglycemia protocol . an error was defined as any dose of insulin given or omitted that deviated from the physician order ( omission of an insulin dose , wrong insulin dose or type , wrong administration time , blood glucose not checked per order or hypoglycemia protocol , and blood glucose not documented in the record ) . patient demographics and details of insulin errors are in table 1 . a total of 100% of the children 's hospital 's registered nursing staff ( n = 283 ) completed the educational module . before intervention the mean number of errors per patient in this sample was 5.20 . in the postintervention sample , the mean number of errors per patient in this sample was 0.86 ( p = 0.003 ) . the number of patients experiencing insulin - related errors during their hospitalization decreased from 21 out of 24 ( 87.5% ) in the preintervention phase to 5 out of 22 ( 22.7% ) postintervention . the overall error rate decreased from 14.8% in the preintervention phase to 1.7% in the postintervention phase ( p < 0.001 ) . study demographics and insulin errors per patient data are means  sd or n ( % ) unless otherwise indicated . glucose may have been found in laboratory data , but not documented as mandated per nursing policy .  percentage based on total possible errors . these findings demonstrate that an interactive online nursing educational module can be an effective strategy for reducing insulin administration errors in hospitalized pediatric patients . multiple studies have found deficits in nurses ' knowledge regarding diabetes ( 911 ) , suggesting that additional education about diabetes is needed in order for nurses to provide safe and effective care to these patients . consistent with phillips ' ( 12 ) recommendation that educational modules provide frequent feedback to learners , our module used a self - paced technological medium that provided active learning , problem solving , and immediate feedback to the nurses . strategies that enhanced implementation included engaging hospital administration support from the beginning of the study ; recruiting nursing unit champions who took ownership of the performance improvement initiative at the unit level and acted as an educational resource for the nursing staff ; and requiring that all nurses view the module . study limitations include limited generalizability due to a small convenience sample of pediatric nurses at a single academic medical center 's children 's hospital . second , although the chart reviewers were not involved in the care of these patients , and therefore were blinded to the medication administration process and documentation , the analysis was done by the same team that collected the data , leaving the possibility of investigator bias . however , the magnitude of the difference between the pre- and postintervention findings makes it likely that a real reduction in errors did in fact occur . finally , using a retrospective chart audit to detect errors was also a limitation , since it relies on the accuracy and adequacy of nursing documentation . in conclusion , this study presents a first attempt to evaluate an effective and feasible method of educating a large number of nurses on the correct implementation of physiologic insulin dosing for hospitalized pediatric patients . more research is needed to validate these findings , as well as to determine how to sustain and disseminate successful educational programs .
objectiveto determine the effectiveness of an online module for reducing insulin administration errors by nurses caring for hospitalized pediatric patients.research design and methodspediatric nursing staff completed a mandatory online educational module teaching insulin pharmacokinetics and the insulin order form , using diluted insulin and finishing with 15 interactive cases . a chart audit to determine all possible insulin errors of patients receiving insulin 
 was done before and 26 months after the educational module.resultsall of the medical center 's 283 pediatric nurses successfully completed the educational module . 
 a total of 24 charts were audited in the preintervention phase and 22 in the postintervention phase . 
 the preintervention insulin error rate was 14.8% , reduced to 1.7% ( p < 0.001 ) postintervention . 
 improvement occurred in correct insulin dosing and type , timing of administration , and timely blood glucose monitoring and documentation.conclusionsan interactive online educational module can be an effective strategy for reducing pediatric nurses ' insulin administration errors .