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The current state of "wrong patient" insulin pen injections
The current state of "wrong patient" insulin pen injections
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Gaunt, Michael J., author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body.
ECRI (Organization), issuing body.
Institute for Safe Medication Practices, issuing body. - Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, September 2015
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Equipment Contamination
Injections
Insulin
Medication Errors -- prevention & control
Medication Errors -- statistics & numerical data
Needles
Pennsylvania
United States - Genre(s):
- Technical Report
- Abstract:
- Thousands of patients in the United States have received injections from potentially contaminated insulin pens, typically involving inappropriate or unrecognized sharing of a patient's previously used insulin pen device. Analyst query of the Pennsylvania Patient Safety Reporting System identified 82 reports of potential or actual wrong-patient errors with the use of insulin pen devices in Pennsylvania from 2005 through 2014. Over half (n = 43) of the reports describe actual administration events, 35.4% (n = 29) were close calls, and the remaining 12.2% (n = 10) did not indicate whether or not administration took place. Nearly two-thirds (n = 54) of the 82 events, including 67.4% (n = 29) of the actual administration events, occurred during 2013 or 2014. Despite widespread media coverage, recommendations from national organizations, and application of strategies considered best practices, wrong-patient insulin pen injections continue to occur. Hospitals are encouraged to analyze their own wrong-patient events with the use of insulin pens and examine their current insulin practices as they decide whether to use insulin pens, vials, or a combination of the two.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (pages ))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101669448 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101669448