Narrow Results Clear All
- Culture of Safety 2
- Error Reporting and Analysis 1
- Quality Improvement Strategies 1
- Technologic Approaches
Search results for "Insulin"
- Administration Errors
- Bar Coding and Radiofrequency ID Tagging
- Health Care Executives and Administrators
Journal Article > Study
Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.
MacMaster HW, Gonzalez S, Maruoka A, et al. Jt Comm J Qual Patient Saf. 2019;45:380-386.
Insulin is a widely used high-risk medication. This quality improvement intervention employed barcode medication administration and a standardized electronic health record–integrated workflow to successfully reduce wrong-patient insulin pen errors. The authors call for widespread implementation of medication safety improvements into electronic health records.
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 > 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
Bates DW. Ann Intern Med. 2002;137:110-116.
This case study shares the experiences of a patient who suffered a medication error in receiving a dose of insulin inadvertently. The author reviews the epidemiology of medication errors and adverse drug events and shares a systems approach to medication errors, the role individuals and the system played in this particular case, and the potential prevention strategies to be considered. Finally, a comment about the institution's response to the event is presented to illustrate the importance of bridging what happens at the bedside with what needs to happen from the executive suite. This article is part of a collection entitled "Quality Grand Rounds," a series published in the Annals of Internal Medicine that explores quality issues and medical errors.