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Cases & Commentaries
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Saul N. Weingart, MD, PhD; August 2006
In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.
Journal Article > Commentary
Rule AM, Drincic A, Galt KA. Jt Comm J Qual Patient Saf. 2007;33:155-162.
The authors share a case report of errors associated with the introduction of new equipment in an ambulatory setting and discuss the importance of device selection and user training to minimize these failures.