AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (5)

•Diagnostic Errors (5)

•Discontinuities, Gaps, and Hand-Off Problems (4)

•Medication Safety (17)

•Medical Complications (2)

Origin/Sponsor

•Australia and New Zealand (1)

•North America (23)

Resource Types

•Book/Report (3)

•Journal Article (16)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (7)

•Press Release/Announcement (3)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (8)

•Active Errors (11)

•Latent Errors (1)

Approach to Improving Safety

•Quality Improvement Strategies (15)

•Legal and Policy Approaches (1)

•Error Reporting and Analysis (7)

•Communication Improvement (6)

•Human Factors Engineering (4)

•Teamwork (3)

•Specialization of Care (2)

•Culture of Safety (4)

•Technologic Approaches (4)

•Education and Training (9)

Clinical Areas
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Endocrinology

Target Audience

•Health Care Providers (25)

•Health Care Executives and Administrators (21)

•Non-Health Care Professionals (4)

•Patients (3)

Setting of Care

•Hospitals (13)

•Ambulatory Care (9)

1 - 20 of 31

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STUDY

Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.

Spiller HA, Borys DJ, Ryan ML, Sawyer TS, Wilson BL. Ann Pharmacother. 2011;45:17-22.

REVIEW

Patient safety systems in the primary health care of diabetes—a story of missed opportunities?

Taub N, Baker R, Khunti K, et al. Diabet Med. 2010;27:1322-1326.

NEWSPAPER/MAGAZINE ARTICLE

An overlooked condition.

Nicholas L. Modern Healthc. November 14, 2005;35:24.

STUDY

Organizational culture, team climate and diabetes care in small office-based practices.

Bosch M, Dijkstra R, Wensing M, van der Weijden T, Grol R. BMC Health Serv Res. 2008;8:180.

STUDY

Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients.

Sarkar U, Handley MA, Gupta R, et al. J Gen Intern Med. 2008;23:459-465.

STUDY

Ambiguities of chronic illness management and challenges to the medical error paradigm.

Lutfey KE, Freese J. Soc Sci Med. 2007;64:314-25.

COMMENTARY

Addressing safety concerns about U-500 insulin in a hospital setting.

Samaan KH, Dahlke M, Stover J. Am J Health Syst Pharm. 2011;68:63-68.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

REVIEW

Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists.

Foy R, Hempel S, Rubenstein L, et al. Ann Intern Med. 2010;152:247-258.

STUDY

Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy.

Dooley MJ, Wiseman M, McRae A, et al. BMJ Qual Saf. 2011;20:637-644.

COMMENTARY

Avoiding errors associated with insulin therapy.

Cohen H. Medscape CME/CE. May 14, 2009.

NEWSPAPER/MAGAZINE ARTICLE

Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis.

Boodman SG. Washington Post. June 13, 2011:E1.

ORGANIZATIONAL POLICY/GUIDELINES

American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology.

Bates D, Clark NG, Cook RI, et al; Writing Committee on Patient Safety and Medical System Errors in Diabetes and Endocrinology. Endocr Pract. 2005;11:197-202.

NEWSPAPER/MAGAZINE ARTICLE

A clinical reminder about the safe use of insulin vials.

ISMP Medication Safety Alert! Acute Care Edition. February 21, 2013;18:1-3.

MULTI-USE WEBSITE

AACE Patient Safety Exchange.

American Association of Clinical Endocrinologists.

STUDY

Finding blunders in thyroid testing: experience in newborns.

Zilka LJ, Lott JA, Baker LC, Linard SM. J Clin Lab Anal. 2008;22:254-256.

STUDY

Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic.

Taylor CR, Hepworth JT, Buerhaus PI, Dittus R, Speroff T. Qual Saf Health Care. 2007;16:244-247.

STUDY

Miscoding, misclassification and misdiagnosis of diabetes in primary care.

de Lusignan S, Sadek N, Mulnier H, Tahir A, Russell-Jones D, Khunti K. Diabet Med. 2012;29:181-189.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors common for hospital diabetes.

Nursing Times. April 1, 2011.

PRESS RELEASE/ANNOUNCEMENT

Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 13, 2009.

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