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Are Two Insulin Pumps Better Than One?
Cook CB. AHRQ WebM&M [serial online]. January 2009.
Admitted to the hospital for surgery, a man with type 1 diabetes mellitus asked the staff to leave his home insulin pump in place but did not mention that he was adjusting his insulin pump himself based on serial glucose measurements. As the patient was also receiving an intravenous insulin infusion, he developed hypoglycemia.
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Commentary
Setting of Care
Hospitals
Target Audience
Health Care Providers
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Clinical Area
Cardiology
Endocrinology
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Safety Target
Infusion Pumps
Medication Errors/Preventable Adverse Drug Events
Insulin
Error Types
Active Errors
Approach to Improving Safety
Critical Pathways
Practice Guidelines