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Search results for "Insulin"
Web Resource > Multi-use Website
American Society of Health-System Pharmacists.
Insulin is classified as a high-alert medication due to the potential to cause serious patient harm when administered incorrectly. This Web site provides information and resources related to an initiative aimed at augmenting pharmacist education about appropriate use of insulin and insulin pens in the hospital setting.
Journal Article > Study
An interprofessional qualitative study of barriers and potential solutions for the safe use of insulin in the hospital setting.
Rousseau MP, Beauchesne MF, Naud AS, et al. Can J Diabetes. 2014;38:85-89.
This focus group study among physicians, nurses, and pharmacists in the hospital setting found that variability in practices for inpatient insulin use contributed to adverse events. The authors advocate for a systems approach to insulin management to enhance safety. A past AHRQ WebM&M commentary suggested that a uniform algorithm for insulin administration be implemented in all acute care settings.
Journal Article > Commentary
McDonald CJ. Ann Intern Med. 2006;144:510-516.
This case study shares the events of a near miss when a patient almost received a fatal dose of insulin in response to another patient's reported hyperglycemia. Ironically, the root cause of the problem involved a new bar-coding system to prevent errors in patient identification. The authors discuss the case in detail and advise caution in the implementation of new technology (eg, computerized provider order entry), which may solve safety issues but create the opportunity for others. This article is part of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.
Journal Article > Study
Characteristics of medication errors made by students during the administration phase: a descriptive study.
Wolf ZR, Hicks R, Serembus JF. J Prof Nurs. 2006;22:39-51.
The authors analyzed reports of drug administration errors by nursing students. They found that omission errors were most common and that student inexperience and distraction were contributing factors.
Cases & Commentaries
- Spotlight Case
- Web M&M
Haya R. Rubin, MD, PhD; Vera T. Fajtova, MD; May 2004
To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic.