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.

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.

Inconsistent and possibly erroneous results of thyroid tests for newborns occurred in 18 patients among 600,000 tested in this study. The authors recommend follow-up studies to determine the reproducibility of these results.

The authors describe one hospital's effort to reduce pediatric insulin prescribing errors by including decision support in their computerized provider order entry system.