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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.
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American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. July 2005;79:65-66.
This brief addresses the role of bar coding in medication safety and includes three case studies of implementation. It is the second in a series of six briefs focusing on medication errors.