The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 129 Results

Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

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WebM&M Case August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.

Insulin pump-associated adverse events: a qualitative descriptive study of clinical consequences and potential root causes.

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Estock JL, Codario RA, Keddem S, et al. Diabetes Technol Ther. 2023;25:343-355.

Insulin pump malfunctions are a known contributor to adverse events. This study used six months of adverse events reported to the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database to identify root causes and consequences of errors associated with insulin pump malfunctions. Hyper- and hypoglycemia were the most common clinical consequences of the malfunction; only half of the reports identified a potential root cause.

Hospital-Acquired Diabetic Ketoacidosis.

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WebM&M Case February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication reconciliation in the emergency department (ED) for high-risk patients on insulin, and strategies to empower patients and caregivers to speak up about medication safety.

Reducing potential errors associated with insulin administration: an integrative review.

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Alqahtani N. J Eval Clin Pract. 2022;28:1037-1049.

Insulin-related errors result in nearly 100,000 emergency department visits annually in the United States, with 30% resulting in hospitalization. It is unclear if published guidelines and strategies for reducing these errors have been effective; therefore, this review sought to identify interventions to reduce insulin errors in home and hospital settings. Three themes emerged: technology, education, and policy. Understanding these findings may help clinicians and patients to decrease insulin administration errors and help researchers develop and evaluate future studies targeting insulin-related errors.

Potentially inappropriate prescribing for adults living with diabetes mellitus: a scoping review.

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Ayalew MB, Spark MJ, Quirk F, et al. Int J Clin Pharm. 2022;44:860-872.

Patients with diabetes, particularly those taking multiple medications, are at increased for medication adverse events. In this review of nearly 200 studies of potentially inappropriate prescribing (PIP) for patients with diabetes, several types of PIPs occurred: contraindication, omission, incorrect dosing, drug-drug interaction, inappropriate drug selection, and unnecessary drug therapy.

Administering High-Strength Insulin from a Pen Device in Hospital.

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Farnborough, UK: Healthcare Safety Investigation Branch; July 7, 2022.

Misuse of insulin pens contributes to never events associated with diabetic medication therapy in hospitalized patients. This investigation of an injurious insulin extraction workaround culminated in recommendations to improve insulin administration safety including the explicit use of pen devices to administer U-500 insulin.

Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices.

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McKay C, Schenkat D, Murphy K, et al. Hosp Pharm. 2022;57:689-696.

Insulin is a high-alert medication due to heightened risk for serious patient harm if administered incorrectly. This review presents types of common errors (e.g., wrong patient, cross-contamination), pros and cons of potential dispensing strategies, and the impact of organizational factors (e.g., workflows, cost) on safe dispensing. Additionally, the authors make recommendations for dispensing, taking organization factors into account.

Challenges of Diabetes Management and Medication Reconciliation

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WebM&M Case August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.

Weight-based Medication Errors in Children.

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Farnborough, UK: Healthcare Safety Investigation Branch; February 2022.

Weight-calculation errors can result in pediatric patient harm as they affect medication prescribing, dispensing, and administration accuracy. This report examines factors contributing to a computation mistake that resulted in a child receiving a 10-fold anticoagulant overdose over a 3-day period. Areas of focus for improvement include use of prescribing technology, and the double-check as an error barrier.

An initiative to reduce insulin-related adverse drug events in a children's hospital.

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Lawson SA, Hornung LN, Lawrence M, et al. Pediatrics. 2022;149:e2020004937.

Insulin is a high-risk medication and can contribute to adverse events in pediatric patients. This paper describes one children’s hospital’s experience implementing a new standardized medication administration process for insulin and the impact on insulin-related adverse drug events (ADEs). Findings indicate that implementation of a PRN (i.e., “as needed”) ordering process and clinician education decreased insulin-related ADEs and reduced the time between blood glucose checks and insulin administration.

Adverse glycemic events and critical emergencies.

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ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.

Insulin is a high-alert medication that requires extra attention to safely manage blood sugar levels in chronic or acutely ill patients. This alert highlights look-alike/sound-alike packaging, delayed medication reconciliation, and dietary monitoring gaps as threats to safe insulin administration in emergencies. Recommendations for improvement are provided for both general in-hospital, and post-discharge care.

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

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Dornan T, Lee C, Findlay-White F, et al. Med Teach. 2021;43:1419-1429.

Health profession students are required to demonstrate competence in a variety of areas related to safe patient care. This article puts forth a recommendation to move beyond core competencies to improve patient safety and clinicians’ mutual safety.

A Sweet Case of Hidden Hydrogen Ions

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WebM&M Case April 28, 2021

A 24-year-old woman with type 1 diabetes presented to the emergency department with worsening abdominal pain, nausea, and vomiting. Her last dose of insulin was one day prior to presentation. She stopped taking insulin because she was not tolerating any oral intake. The admitting team managed her diabetes with subcutaneous insulin but thought the patient did not meet criteria for diabetic ketoacidosis (DKA), but after three inpatient days with persistent hyperglycemia, blurred vision, and altered mental status, a consulting endocrinologist diagnosed DKA.

Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017.

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Geller AI, Conrad AO, Weidle NJ, et al. Pharmacoepidemiol Drug Saf. 2021;30:573-581.

The Institute for Safe Medication Practices (ISMP) classifies insulin as a high-risk medication. This study examines insulin mix-up errors that resulted in emergency department visits or other serious adverse events. Most cases of medication mix-up involved rapid-acting insulin. Recommended prevention strategies include increased patient education and human factors engineering.

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

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Gurwitz JH, Kapoor A, Garber L, et al. JAMA Intern Med. 2021;181:610-618.

High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.

Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education.

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Wei ET, Koh E, Kelly MS, et al. J Am Pharm Assoc (2003). 2020;60:e76-e80.

Insulin is a high-risk medication that can lead to harm if administered incorrectly. This article describes four cases highlighting the importance of providing appropriate education on injectable antidiabetic medications, common diabetes-related medication errors in primary care, identifying patients who may be at high risk and ways to prevent these errors.

Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump

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WebM&M Case October 28, 2020

A 14-year-old girl with type 1 diabetes (T1D) was admitted to the hospital after two weeks of heavy menstrual bleeding as well as blurred vision, headache and left arm numbness. MRI revealed an acute right middle cerebral artery (MCA) infarct.

FDA advises health care professionals and patients about insulin pen packaging and dispensing.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 13, 2020.

Insulin use errors are common despite their heightened potential for patient harm. This announcement highlights labeling and storage practices to reduce dispensing and administration errors associated with individual insulin pen use.

Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center.

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Ho S, Stamm R, Hibbs M, et al. Jt Comm J Qual Patient Saf. 2019;45:814-821.

Recent guidelines from the Institute for Safe Medication Practices have warned of the risk of blood-borne disease transmission associated with insulin pen sharing in hospitalized patients and provide recommendations for safe practices. This paper describes the impact on insulin pen sharing after the implementation of safe practice recommendations (e.g., label redesign, patient-specific bar coding on pens) at a quaternary academic medical center. Institutional efforts resulted in a less frequent pen-sharing events and a decrease in latent errors found during medication drawer audits, such as retained pens after discharge and illegible or missing label.

Improving the quality of insulin prescribing for people with diabetes being discharged from hospital

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Bain A, Silcock J, Kavanagh S, et al. BMJ Open Qual. 2019;8:e000655.

Medication errors involving insulin are common, particularly in hospitals and at point-of-care transfers. Using a continuous improvement methodology, a multidisciplinary project team carried out three “plan-do-study-act" cycles to introduce locally tailored insulin discharge prescribing guidance. Adherence to the guidelines improved from an average of 50% to 99% after introduction of a poster and then checklist forms of the guidelines. This small, qualitative study in one hospital diabetes ward suggests that small iterative changes can improve insulin discharge prescription quality. A PSNet primer expands on the topic of medication reconciliation.

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