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Approach to Improving Safety
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Search results for "United States of America"

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Book/Report

ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults.

Horsham, PA: Institute for Safe Medication Practices; May 2017.

Insulin is a widely used medication that can contribute to serious patient harm if used incorrectly. This report provides information about problems associated with insulin use in adults and offers consensus-developed strategies to encourage subcutaneous insulin practices that reduce errors at the prescribing, pharmacy management, administration, and transition phases.

Journal Article > Review

The challenges of electronic health records and diabetes electronic prescribing: implications for safety net care for diverse populations.

Ratanawongsa N, Chan LLS, Fouts MM, Murphy EJ. J Diabetes Res. 2017;2017:8983237.

Diabetes medications are known to be high risk for adverse drug events. This case study reviews several patient safety measures for electronic prescribing for diabetes in outpatient care. Researchers describe an adverse drug event involving electronic prescribing of insulin and detail how the incident could have been prevented. Electronic prescribing is not currently standardized and may require using a trade name for medications, which may lead to prescribing errors. Adoption of the medication naming conventions put forth by the National Library of Medicine's RxNorm would prevent this vulnerability. Similarly, standardizing electronic prescribing orders for high-risk medications like insulin may reduce the risk of erroneously choosing a long-acting instead of short-acting insulin formulation, which can have life-threatening consequences. The authors advocate for using Universal Medication Schedule instructions and providing language-concordant labels to patients to support safe medication self-administration. They suggest that real-time, bidirectional communication between prescribers and pharmacists may improve safe prescribing. The authors conclude that recommended safety practices are not uniformly implemented in clinical practice and advocate for implementation research to ensure medication safety for outpatients with diabetes.

Journal Article > Study

Medication errors associated with transition from insulin pens to insulin vials.

Trimble AN, Bishop B, Rampe N. Am J Health Syst Pharm. 2017;74:70-75.

Insulin is a high-risk medication. This pre–post study examined the risk for insulin dosing errors after a transition from insulin pens to vials. Three major insulin administration errors occurred, which led to training and process changes in order to mitigate the risk of harm.

Journal Article > Study

Determining current insulin pen use practices and errors in the inpatient setting.

Brown KE, Hertig JB. Jt Comm J Qual Patient Saf. 2016;42:568-582.

Medication errors related to insulin use are common. This survey study sought to characterize current insulin pen use and associated safety issues in the inpatient setting. Investigators found that insulin pens are widely utilized, but safety issues—such as using the same pen on multiple patients—persist. The authors suggest that further research is needed regarding how to mitigate risks associated with insulin pen use.

Press Release/Announcement

Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics.

Federal Register. Washington, DC: Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. October 20, 2016;81:72594-72595.

National attention has focused on efforts to address adverse drug events. This call for comments seeks insights regarding revisions to a 2014 action plan that highlighted how to reduce adverse drug events associated with anticoagulants, diabetes agents, and opioids. These proposed updates involve measures to apply in both the inpatient and outpatient environments to track adverse drug events. The opportunity to submit written comments is now closed.

Special or Theme Issue

Insulin Pens Devices.

Am J Health Syst Pharm. 2016;73(19 suppl 5);S1-S47.

As a high-alert medication, insulin has the potential to result in serious patient harm if administered incorrectly. Articles in this special issue discuss recommendations developed to address risks associated with pen injector practices and the results of an improvement initiative to enhance the safe use of insulin pens. Mentoring and safety culture are highlighted as areas that support improvements.

Newspaper/Magazine Article

Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.

ISMP Medication Safety Alert! Acute Care Edition. May 5, 2016;21:1-4.

Insulin is a high-alert drug, and its use is becoming more complex due to the insulin resistance in diabetic patients with obesity. This newsletter article describes the experience of one hospital system that worked to ensure safe insulin administration by implementing a strategy that combined single-use pens and health information technology.

Journal Article > Study

Does an insulin double-checking procedure improve patient safety?

Modic MB, Albert NM, Sun Z, et al. J Nurs Adm. 2016;46:154-160.

Insulin is a high-risk medication, and The Joint Commission and Institute for Safe Medication Practices recommend that hospital insulin administration be double-checked by nurses. This randomized trial found that double-checking insulin can result in fewer administration errors.

Journal Article > Commentary

Advancing medication safety: establishing a National Action Plan for Adverse Drug Event Prevention.

Harris Y, Hu DJ, Lee C, Mistry M, York A, Johnson TK. Jt Comm J Qual Patient Saf. 2015;41:351-360.

Adverse drug events continue to contribute to preventable errors for both hospitalized and ambulatory patients. This commentary describes the development and implementation plans of a national effort to reduce adverse drug events in the United States.

Web Resource > Multi-use Website

Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital.

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.

Newspaper/Magazine Article

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 > Study

National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations.

Geller AI, Shehab N, Lovegrove MC, et al. JAMA Intern Med. 2014;174:678-686.

According to this large study, nearly 100,000 emergency department visits and 30,000 hospitalizations in the United States each year are due to insulin-related hypoglycemia and errors. Patients older than 80 years were found to be at highest risk for these adverse events.

Newspaper/Magazine Article

A clinical reminder about the safe use of insulin vials.

ISMP Medication Safety Alert! Acute Care Edition. February 21, 2013;18:1-3.

This newsletter piece recommends strategies to ensure the safe transition from using insulin pens to insulin vials in acute care.

Newspaper/Magazine Article

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

This article discusses incidents involving misadministration of IV insulin and makes recommendations to improve safety in delivering this high-alert medication.

Journal Article > Commentary

Addressing safety concerns about U-500 insulin in a hospital setting.

Samaan KH, Dahlke M, Stover J. Am J Health Syst Pharm. 2011;68:63-68.

This commentary describes how a community hospital implemented a multi-component program to ensure that U-500 insulin was administered safely.

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 > Study

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

In this study, investigators identified possible medication errors using trigger tools, and a multidisciplinary team conducted real-time analyses to identify underlying system flaws contributing to the errors.

Newspaper/Magazine Article

Common cause analysis.

Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.

This article describes how one health care system used a multi-event analysis process to identify medication errors, implement system-level improvements, and reduce adverse events.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355. 

This monthly selection of error reports discusses incidents involving look-alike drug names, concentration dosage error, and harm related to abbreviation use.

Journal Article > Study

Improving insulin distribution and administration safety using Lean Six Sigma methodologies.

Yamamoto J, Abraham D, Malatestinic B. Hosp Pharm. 2010;45:212-224.

In this collaboration between a pharmaceutical company and a hospital, Six Sigma methodology was used to standardize and improve the efficiency of insulin dispensing and administration. The intervention resulted in cost savings and a reduction in clinical adverse events.

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