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Forgotten Med.
Cucina R. AHRQ WebM&M [serial online]. April 2005.
Thinking that the patient’s glycemic control had spontaneously improved (and not realizing that the patient was continuing to receive long-acting insulin injections), a physician discontinues daily glucose checks and insulin sliding scale orders. Four days later, the patient is found unresponsive and hypoglycemic.
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Resource Type
Commentary
Setting of Care
Residential Facilities
Target Audience
Physicians
Nurses
Safety Target
Ordering/Prescribing Errors
Insulin
Error Types
Latent Errors
Approach to Improving Safety
Forcing Functions
Computerized Provider Order Entry (CPOE)
Computerized Decision Support
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)