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Cases & Commentaries
- Web M&M
Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
This article describes how one health care system used a multi-event analysis process to identify medication errors, implement system-level improvements, and reduce adverse events.
Journal Article > Study
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.
In this study, investigators identified possible medication errors using trigger tools, and a multidisciplinary team conducted real-time analyses to identify underlying system flaws contributing to the errors.
Journal Article > Review
Cornish W. Can J Diabetes. 2014;38:94-100.
Insulin is a high-alert medication due to the potential for serious patient harm resulting from inappropriate administration. This review describes tactics to enhance safe insulin use, including improved attention to contraindications, clinical decision support implementation, and education for providers about glycemic control.
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
Improper insulin pen use is a persistent problem. This newsletter article reveals the lessons learned from one hospital that implemented best practices including robust education, bar-code scanning, bedside electronic medication administration records, and alerts to prevent incorrect administration but continued to experience errors related to insulin pen use.
Journal Article > Study
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.
This retrospective study examined possible transcription errors for blood glucose values among patients in a surgical intensive care unit for which glucometers did not connect with the electronic health record. Investigators identified multiple insulin dosing errors as a result of transcription errors. They spotlight the need for interoperability between glucometers and electronic health records.