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Search results for "Cognitive Errors ("Mistakes")"
- Cognitive Errors ("Mistakes")
Journal Article > Study
Gibbs HG, McLernon T, Call R, et al. Am J Health Syst Pharm. 2017;74:2054-2059.
This quality improvement intervention sought to decrease wrong-patient errors with insulin pens by storing them in locked boxes in patient rooms. Four hospital units had a formal policy change for insulin pen storage, and four units provided education to nurses about insulin pen storage. Researchers found that the policy change was more effective than education in spurring adherence to in-room insulin pen storage guidelines.
Cases & Commentaries
- Spotlight Case
- Web M&M
Patricia Juang, MD, and Kristen Kulasa, MD; April 2016
While hospitalized, a man with diabetes had difficult-to-control blood sugars, with multiple episodes of both critical hypoglycemia and serious hyperglycemia. Because "holds" of the patient's insulin were not clearly documented in the electronic health record and blood sugar readings were not uploaded in real time, providers were unaware of how much insulin had actually been given.