Medication errors with the dosing of insulin: problems across the continuum

Medication errors with the dosing of insulin: problems across the continuum

Collection:
Health Policy and Services Research
Series Title(s):
Pennsylvania patient safety advisory
Contributor(s):
Pennsylvania. Patient Safety Authority.
ECRI (Organization)
Institute for Safe Medication Practices.
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2010
Language(s):
English
Format:
Text
Subject(s):
Hyperglycemia -- drug therapy
Insulin -- administration & dosage
Medication Errors -- prevention & control
Pennsylvania
United States
Genre(s):
Technical Report
Abstract:
Controlling blood sugars with insulin is essential in the management of hyperglycemia in both diabetic and nondiabetic patients. However, studies have shown that the use of insulin has been associated with more medication errors than any other type or class of drug. From January 2008 to June 6, 2009, Pennsylvania healthcare facilities submitted 2,685 event reports to the Authority that mentioned medication errors involving the use of insulin products. The most common types of medication error associated with insulin were drug omission (24.7%) followed by wrong-drug errors (13.9%). More than 52% of the reported events led to situations in which a patient may have or actually received the wrong dose or no dose of insulin (e.g., dose omissions, wrong dose/overdosage, wrong dose/underdosage, extra dose, wrong rate errors), which could lead to difficulties in glycemic control. Strategies to address these problems include limiting the variety of insulin products on the organization's formularies, developing standardized protocols and a standard format for prescribing insulin, avoiding the use of abbreviations or other shortcuts when communicating orders for insulin, and requiring an independent double check of all doses before dispensing and administering intravenous insulin.
Copyright:
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
Illustrations:
Illustrations
NLM Unique ID:
101567373 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/101567373