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National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. October 12, 2017.
Care devices that enable patients to administer medicines at home can have unintended consequences. This alert raises awareness of hazards related to insulin pen misuse and offers recommendations to reduce risks, such as training patients to properly use pen needles and engaging community pharmacists in verifying that patients understand appropriate administration techniques.
Journal Article > Study
Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.
Spiller HA, Borys DJ, Ryan ML, Sawyer TS, Wilson BL. Ann Pharmacother. 2011;45:17-22.
Preventing medication errors remains a focus of safety interventions, particularly for high-risk medications such as insulin. While insulin-related adverse events are well described in hospital and nursing home settings, the scope of the problem in ambulatory care is less understood. This study analyzed nearly 4000 insulin exposures reported to poison centers over the past decade and found a mean annual increase of 18% over that time period. Unintentional therapeutic errors accounted for 68% of the total with a progression from 41% to 78% over the study period. Factors associated with these errors included adults older than 40 years and administration in the late evening hours. These findings raise opportunities for improvement in insulin safety outside the heavily studied inpatient setting. A past AHRQ WebM&M commentary discussed the challenges in managing insulin therapy in the hospital setting.
Journal Article > Commentary
Rule AM, Drincic A, Galt KA. Jt Comm J Qual Patient Saf. 2007;33:155-162.
The authors share a case report of errors associated with the introduction of new equipment in an ambulatory setting and discuss the importance of device selection and user training to minimize these failures.
Journal Article > Study
Insulin treatment as a tracer for identifying latent patient safety risks in home-based diabetes care.
Odegard S, Andersson DK. J Nurs Manag. March 2006;14:116-127.
The investigators surveyed Swedish municipal health care workers and found that attitudes about patient safety among nurses with medical responsibility may heighten the risk of home care aides' making errors in caring for diabetes patients.