Medication errors associated with transition from insulin pens to insulin vials.

Adam N. Trimble; Bryan Bishop; Nancy Rampe

Study

Medication errors associated with transition from insulin pens to insulin vials.

March 8, 2017

Trimble AN, Bishop B, Rampe N. Am J Health Syst Pharm. 2017;74(2):70-75.

View more articles from the same authors.

Insulin is a high-risk medication. This pre–post study examined the risk for insulin dosing errors after a transition from insulin pens to vials. Three major insulin administration errors occurred, which led to training and process changes in order to mitigate the risk of harm.

PubMed citation

Available at

Related Resources From the Same Author(s)

The thinking doctor: clinical decision making in contemporary medicine.

August 31, 2016

Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans.

November 2, 2011

Medicare's decision to withhold payment for hospital errors: the devil is in the details.

January 30, 2008

Stop the silent misdiagnosis: patients' preferences matter.

November 21, 2012

Medical groups' adoption of electronic health records and information systems.

October 5, 2005

HIPAA and patient care: the role for professional judgment.

May 4, 2005

"Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient safety.

September 1, 2010

Patient involvement in patient safety: a qualitative study of nursing staff and patient perceptions.

August 13, 2014

Framework for analysing risk and safety in clinical medicine.

July 17, 2013

Framework for analysing risk and safety in clinical medicine.

July 17, 2013

The role of safety culture in influencing provider perceptions of patient safety.

December 14, 2016

Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis.

August 7, 2013

Health care provider use of private sector internal error-reporting systems.

November 30, 2005

Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: a systematic review.

December 11, 2019

An exploratory study of knowledge brokering in hospital settings: facilitating knowledge sharing and learning for patient safety?

January 29, 2014

Introduction of surgical safety checklists in Ontario, Canada.

March 19, 2014

'I think this medicine actually killed my wife': patient and family perspectives on shared decision-making to optimize medications and safety.

July 17, 2019

Applying Lean methods to improve quality and safety in surgical sterile instrument processing.

March 13, 2013

Economic outcomes associated with safety interventions by a pharmacist–adjudicated prior authorization consult service.

May 29, 2019

Implementation of a second victim program in the neonatal intensive care unit: an interim analysis of employee satisfaction.

January 23, 2019

Reducing errors through discharge medication reconciliation by pharmacy services.

August 26, 2015

Usability study of two common defibrillators reveals hazards.

January 2, 2008

Deployment of a second victim peer support program: a replication study.

August 16, 2017

Paid malpractice claims for adverse events in inpatient and outpatient settings.

January 30, 2005

Toward higher-performance health systems: adults' health care experiences in seven countries, 2007.

November 14, 2007

Mortality rate after nonelective hospital admission.

June 1, 2011

Outcomes of daytime procedures performed by attending surgeons after night work.

September 2, 2015

Inappropriate medication in a national sample of US elderly patients receiving home health care.

October 26, 2011

Quality and safety in medical care: what does the future hold?

November 23, 2011

Addressing the nursing work environment to promote patient safety.

February 7, 2007

Workarounds are routinely used by nurses—but are they ethical?

November 8, 2017

Residents' perspective on the impact of the 80-hour workweek policy.

June 11, 2008

The emotional impact of errors or adverse events on healthcare providers in the NICU: the protective role of coworker support.

April 25, 2018

Validation of the second victim experience and support tool-revised in the neonatal intensive care unit.

January 12, 2022

Improving safety through speaking up: an ethical and financial imperative.

July 24, 2019

Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals.

December 17, 2008

Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults.

March 3, 2010

Saying "I'm sorry": error disclosure for ophthalmologists.

October 22, 2014

Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds.

October 27, 2021

Iatrogenic delirium and coma: a "near miss."

May 21, 2008

Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view.

July 16, 2008

Promoting patient safety with perioperative hand-off communication.

August 10, 2016

Laboratory testing in general practice: a patient safety blind spot.

November 4, 2015

Using the ABCs of situational awareness for patient safety.

June 5, 2013

Multidisciplinary in-hospital teams improve patient outcomes: a review.

October 22, 2014

2009 National Patient Safety Goals.

April 15, 2009

Rx for medication errors.

November 19, 2008

Always having to say you're sorry: an ethical response to making mistakes in professional practice.

March 6, 2005

National surveillance of emergency department visits for outpatient adverse drug events in children and adolescents.

March 5, 2008

Uptake of quality-related event standards of practice by community pharmacies.

April 30, 2014

Diagnostic errors and diagnostic calibration.

September 6, 2017

Preventing diagnostic errors in ambulatory care: an electronic notification tool for incomplete radiology tests.

May 13, 2020

My brother's keeper: must a physician disclose another's medical error and potential negligence?

January 2, 2008

Assessment of automating safety surveillance from electronic health records: analysis for the quality and safety review system.

September 20, 2017

Awareness and use of a cognitive aid for anesthesiology.

September 19, 2007

Time-out: the professional and organizational ethics of speaking up in the OR.

October 26, 2016

Just culture: it's more than policy.

August 7, 2019

Maintaining maternal-newborn safety during the COVID-19 pandemic.

May 26, 2021

The impact of dedicated medication nurses on the medication administration error rate: a randomized controlled trial.

March 27, 2005

Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ?

March 29, 2006

Frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose.

May 21, 2008

The meaning of justice in safety incident reporting.

November 7, 2007

The effect of the fit between organizational culture and structure on medication errors in medical group practices.

February 7, 2007

Commonly used, easily confused: let's eliminate hyper and hypo.

November 10, 2010

Restricting resident work hours: the good, the bad, and the ugly.

March 21, 2012

A new category of "never events"-ending harmful hospital policies.

November 9, 2022

Peer support and second victim programs for anesthesia professionals involved in stressful or traumatic clinical events.

February 21, 2024

Infusing fun into quality and safety initiatives.

January 30, 2013

The content and context of change of shift report on medical and surgical units.

October 21, 2009

Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review.

March 20, 2013

Research on nursing handoffs for medical and surgical settings: an integrative review.

July 25, 2012

The systems approach to medicine: controversy and misconceptions.

September 3, 2014

Struggling to invent high-reliability organizations in health care settings: insights from the field.

July 19, 2006

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

August 11, 2010

Comparison of barcode scanning by pharmacy technicians and pharmacists' visual checks for final product verification.

February 17, 2016

What have we learnt after 15 years of research into the 'weekend effect'?

January 25, 2017

Safety during night shifts: a cross-sectional survey of junior doctors' preparation and practice.

October 23, 2013

Wrong site surgery.

August 9, 2006

Transfer of accountability: transforming shift handover to enhance patient safety.

November 22, 2006

Understanding interrater reliability and validity of risk assessment tools used to predict adverse clinical events.

March 15, 2017

Reviewing the impact of computerized provider order entry on clinical outcomes: the quality of systematic reviews.

March 7, 2012

Hardwiring patient blood management: harnessing information technology to optimize transfusion practice.

October 22, 2014

Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety.

August 27, 2014

Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning.

May 5, 2021

Nursing student errors and near misses: three years of data.

February 22, 2023

Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative study.

November 17, 2021

The state of the evidence for computerized provider order entry: a systematic review and analysis of the quality of the literature.

February 11, 2009

Framing patient safety initiatives: working model and case example.

April 26, 2006

Toward a theory of self-reconciliation following mistakes in nursing practice.

June 13, 2007

Variation in safety culture dimensions within and between US and Swiss Hospital units: an exploratory study.

August 29, 2012

Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice.

March 11, 2015

Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children.

December 21, 2005

The Patient Safety and Quality Improvement Act of 2005: developing an error reporting system to improve patient safety.

March 26, 2008

The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities.

January 31, 2007

The influence of the structure and culture of medical group practices on prescription drug errors.

August 31, 2005

Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not?

July 23, 2008

Pharmacist work stress and learning from quality related events.

November 9, 2016

Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions.

November 24, 2010

Walking a tightrope: balancing the risk of diagnostic error in inpatient pediatrics.

November 30, 2016

From guideline to order set to patient harm.

April 4, 2018

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Adverse Health Events in Minnesota: Annual Reports.

September 30, 2023

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

October 5, 2022

WebM&M Cases

Challenges of Diabetes Management and Medication Reconciliation

August 5, 2022

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs.

March 2, 2022

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

October 13, 2021

Suicide and suicide attempts on hospital grounds and clinic areas.

August 11, 2021

The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment.

July 14, 2021

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

June 23, 2021

WebM&M Cases

A Sweet Case of Hidden Hydrogen Ions

April 28, 2021

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

March 24, 2021

Implementing a human factors approach to RCA(2) : tools, processes and strategies.

March 10, 2021

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.

February 24, 2021

The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making.

January 27, 2021

A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes.

November 4, 2020

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units.

September 23, 2020

Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.

July 22, 2020

Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data.

July 22, 2020

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.

January 29, 2020

WebM&M Cases

“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event

January 29, 2020

Multidisciplinary simulation activity effectively prepares residents for participation in patient safety activities.

October 16, 2019

A lethal hidden curriculum—death of a medical student from opioid use disorder.

September 4, 2019

Error Reduction and Prevention in Surgical Pathology, Second Edition.

August 28, 2019

Sharing lessons learned to prevent adverse events in anesthesiology nationwide.

August 21, 2019

The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.

May 15, 2019

The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.

February 27, 2019

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments.

August 15, 2018

See More About The Topic

Epidemiology of Errors and Adverse Events

Medication errors associated with transition from insulin pens to insulin vials.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Medication errors associated with transition from insulin pens to insulin vials.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site