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Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Jt Comm J Qual Saf. 2004;30:5-14.
Rozich JD ; Howard RJ ; Justeson JM ; Resar RK.; et al. Standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf. 2004; 30: 14-May
High-Risk Medications, High-Risk Transfers
Nancy Staggers, PhD, RN
Transcription errors of blood glucose values and insulin errors in an intensive care unit: secondary data analysis toward electronic medical record–glucometer interoperability.
Sowan AK, Vera A, Malshe A, Reed C. JMIR Med Inform. 2019;7:e11873.
Insulin pumps have most reported problems in FDA database.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.
MacMaster HW, Gonzalez S, Maruoka A, et al. Jt Comm J Qual Patient Saf. 2019;45:380-386.
Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors.
Singh A, Adams A, Dudley B, Davison E, Jones L, Wales L. BMJ Open Qual 2018;7:e000312.
Insulin dosing error in a patient with severe hyperkalemia.
Hewitt DB, Barnard C, Bilimoria KY. JAMA. 2017;318:2485-2486.
Randomized controlled evaluation of an insulin pen storage policy.
Gibbs HG, McLernon T, Call R, et al. Am J Health Syst Pharm. 2017;74:2054-2059.
Severe hyperglycemia in patients incorrectly using insulin pens at home.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. October 12, 2017.
ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults.
Horsham, PA: Institute for Safe Medication Practices; May 2017.
The challenges of electronic health records and diabetes electronic prescribing: implications for safety net care for diverse populations.
Ratanawongsa N, Chan LLS, Fouts MM, Murphy EJ. J Diabetes Res. 2017;2017:8983237.
Medication errors associated with transition from insulin pens to insulin vials.
Trimble AN, Bishop B, Rampe N. Am J Health Syst Pharm. 2017;74:70-75.
Reduction of medication errors related to sliding scale insulin by the introduction of a standardized order sheet.
Harada S, Suzuki A, Nishida S, et al. J Eval Clin Pract. 2017;23:582-585.
Determining current insulin pen use practices and errors in the inpatient setting.
Brown KE, Hertig JB. Jt Comm J Qual Patient Saf. 2016;42:568-582.
Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics.
Federal Register. Washington, DC: Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. October 20, 2016;81:72594-72595.
Insulin Pens Devices.
Am J Health Syst Pharm. 2016;73(19 suppl 5);S1-S47.
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2016;21:1-4.
Does an insulin double-checking procedure improve patient safety?
Modic MB, Albert NM, Sun Z, et al. J Nurs Adm. 2016;46:154-160.
A clinical reminder about the safe use of insulin vials.
ISMP Medication Safety Alert! Acute Care Edition. February 21, 2013;18:1-3.
Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.
ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.
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.
Medication errors common for hospital diabetes.
Nursing Times. April 1, 2011.
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.
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.
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.
Common cause analysis.
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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