Make Insulin Verification Mandatory in all hospitals and not leave it up to human error.

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The Statistics:

On average, at least one medication error per hospital patient occurs each day, which equals 400,000 errors each year. The extra medical cost of treating drug-related injuries occurring in hospitals alone conservatively amounts to $3.5 billion annually. The Inspector General from the Department of Health and Human Services states that, “Hospital incident reporting doesn’t capture most patient harm.”  It could be much worse than estimated if hospitals are not reporting all errors, and much more expensive. The National Institutes for Health reports that, “Between 2005 and 2007, medical errors cost Medicare more than $6.9 billion and were responsible for more than 92,000 potentially preventable in-hospital deaths among the plan’s beneficiaries."

Of all medical errors, medication administration mistakes have ranked among the most common, harming at least 1.5 million people every year, according to a 2006 report from the Institute of Medicine of the National Academies (IMNA). What is clear is that there needs to be improvements on how medication is administered and recorded. One thing about the clinical trials that will be conducted by Digital Hospital, Inc. is that the medical device is designed to demonstrate exactly how many undocumented medical errors there are and what percent of insulin doses would potentially have been administered in error, as well as the magnitude of the error.This is in addition to accurately measuring insulin doses, the type of medication and bar-coding the dose for communication with the hospital's electronic health record. (Read more about this below.)

Industry recommendations boil down to ensuring that health care providers have the tools and data necessary to prescribe, dispense, and administer drugs as safely as possible and to monitor for problems. Bar coding, combined with other techniques, is helping hospitals forge a new drug safety strategy. But, there is one drug that is NOT currently included in this medication verification system; medications that can either be life saving or life threatening: Insulin.

The Problem:

There is not currently an effective way to verify the type and amount of insulin administered in a hospital setting, nor is there a way to verify that the medication is administered to the correct patient. That’s because nothing currently exists to measure liquid medication under 1mL. 1/3 of fatal medical errors in the hospital among diabetics are due to insulin medication errors because insulin administration is the only medication that is currently vulnerable to human error.

To understand this gap, one must understand how medications are currently being administered in hospitals.

Currently, most hospitals have bedside medication verification systems in place to help improve hospital safety. When the pharmacy enters a medication order for a patient, that information is uploaded to the patient’s electronic health record (EHR). The pharmacist ensures that the medication has a bar-code label before it leaves the pharmacy. A nurse dispensing the medication at the point of care scans the label on the drug and the bar code on the patient’s identification bracelet to ensure that the right patient is receiving the right dose of the right drug at the right time. If there is any deviation, such as if a medication is dispensed before the proper time, the system flags the nurse. This helps improve patient safety, because when a nurse scans the medication and the bar-code software realizes that the wrong patient is about to be given that medication, the medication cannot be dispensed. Before, the odds were [that] the patient would have received the medication. That is what is happening now with Insulin administration. Insulin has been left out due to the lack of available technology to effectively measure liquid medication under 1Ml while digitally communicating the dose with the hospital’s EHR. That’s the key. For most medications, EHR’s verify the prescribed drug and the dose is administered to the correct patient by matching the doctor’s order in the EHR with the bar code printed on the medication package. When the nurse scans the correct drug and dose for the correct patient, she or he receives confirmation the drug is safe to administer. Scanning the medication also automatically documents administration in the EHR. However, insulin remains a significant exception to this important safety feature.

So why doesn't anyone do something about it? Someone has. And if the technology exists to reduce deaths and make hospitals safer, why aren't any of the big organizations using it?  Digital Hospital, Inc. is a start-up that needs funding to create and manufacture more prototypes and conduct clinical testing. But the technology is here, and we need help creating the demand for change.

For the first time in global history, Digital Hospital, Inc. offers a closed loop insulin medication safety strategy. They have developed a medical device and software that makes nurses’ jobs less stressful, saves money and makes hospitals safer for patients. Their Volumetric Smart Sensor (VSS) medical device enables the accurate verification and documentation of insulin administered in a hospital setting because it can accurately measure liquid medication under 1mL. Patients would receive the correct medication and the correct dose at the correct time. And because the interaction is reported to the EHR nurses will know how many potential insulin errors occurred and the magnitude of each.

Imagine the benefit to Medicare and Medicaid when insulin can finally be digitally recorded? Imagine all the money that the non-profits use out of your pockets to try and capture medical errors that can now be captured by this technology.

The medical device works in this way- it discerns the correct type and dosage of insulin in a syringe. If the type and amount of insulin prepared matches the prescription in the hospital's electronic health record (EHR), the nurse receives positive feedback from the system and a label is produced to attach to the syringe. At the point of administration, the syringe label is scanned and the type and dosage of insulin is automatically recorded in the patient’s EHR.  Please see the Nurse Workflow Video at for a demonstration on how it works so you can understand the impacts this could have for the future of medicine.

Here's our frustration. We've been applying for funding at over 100 different VC's, we've contacted ISMP, we've send letters of inquiry to hundreds of corporations, Angel investors and not one of them understand the implications enough to make a investment for change. This is the future people. This will be the way insulin is measured in the future. Yet moving it in to the hospitals for usage has become a 5 year fight. No one will open the doors. Which leads me to this..a campaign for change.

VSS makes the process faster, more affordable and more accurate than current practice. (No other device currently exists on the market today that is capable of accurately measuring volumes less than 1 mL).

Our device saves the nurse time by automatically documenting the administration of insulin at the bedside. The lack of a device that can verify dosage errors under 1 mL has caused dosing errors in hospitals all over the world. This device will reduce human error, and we are confident it will reduce medical mistakes in hospitals resulting lives saved.

Digital Hospital, Inc. has a patented, working prototype (proof of concept) that has been proven to accurately measure the dosage of insulin in a syringe and report the activity. Please sign this petition for change and help save the life of a diabetic you know or perhaps someone suffering the opiod crisis. This can effectively help measure this medication too. Stand with us for positive change and please help us get this technology into hospitals. It will happen, but the sooner, the better for millions of people. Thank you for your support.

Debra Ward

Volunteer for Digital Hospital, Inc.

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