Pharmacists' role in ensuring safe and effective hospital use of insulin

American Journal of Health-System Pharmacy

Volumn 67, Issue 16 SUPPL. 8, 2010, Pages

  Cohen, Michael R ^a  

^a INSTITUTE FOR SAFE MEDICATION PRACTICES   (United States)

Author keywords

Abbreviations; Dosage; Drug administration; Errors, medication; Hospitals; Insulin; Insulins; Pharmaceutical services; Pharmacists, hospital; Prescribing; Protocols; Storage; Toxicity

Indexed keywords

INSULIN; INSULIN ASPART; INSULIN LISPRO; ISOPHANE INSULIN; ANTIDIABETIC AGENT;

CONFERENCE PAPER; DIABETES MELLITUS; DRUG CONTAMINATION; DRUG DELIVERY SYSTEM; DRUG EFFECT; DRUG LABELING; DRUG OVERDOSE; DRUG SAFETY; DRUG STORAGE; DRUG USE; FOOD INTAKE; GLUCOSE BLOOD LEVEL; HOSPITAL; HOSPITAL PATIENT; HUMAN; HYPERGLYCEMIA; HYPOGLYCEMIA; INSULIN TREATMENT; INTERPERSONAL COMMUNICATION; MEDICATION ERROR; NEEDLE; NURSE; PHARMACIST ATTITUDE; PHARMACY; PRESCRIPTION; PRIORITY JOURNAL; RISK MANAGEMENT; STAFF TRAINING; SYRINGE; ARTICLE; CLINICAL PROTOCOL; HOSPITAL PHARMACY; PHARMACIST; PROFESSIONAL STANDARD;

CLINICAL PROTOCOLS; HUMANS; HYPERGLYCEMIA; HYPOGLYCEMIC AGENTS; INPATIENTS; INSULIN; MEDICATION ERRORS; PHARMACISTS; PHARMACY SERVICE, HOSPITAL; PROFESSIONAL ROLE;

EID: 78149474010     PISSN: 10792082     EISSN: 15352900     Source Type: Journal    
DOI: 10.2146/ajhp100173     Document Type: Conference Paper

References (33)

1. Institute for Safe Medication Practices. ISMP 2007 survey on high-alert medications: differences between nursing and pharmacy perspectives still prevalent. www.ismp.org/Newsletters/acutecare/articles/20070517.asp (accessed 2010 Jan 29).
2. Institute for Healthcare Improvement. 5 Million Lives campaign. Getting started kit: prevent harm from high-alert medications. Cambridge, MA: 2008.
3. Joint Commission. High-alert medications and patient safety. www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea-11.htm (accessed 2010 Jan 29).
4. Moore TJ, Cohen MR, Furberg CD. Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. Arch Intern Med. 2007; 167:1752-9. (Pubitemid 47403063)
5. U.S. Pharmacopeia. USP Patient Safety CAPSLink. Section I. Insulin errors: a common problem. www.usp.org/pdf/EN/patientSafety/capsLink2003-07-01. pdf (accessed 2010 Feb 12).
6. Federico F. Preventing harm from high-alert medications. Jt Comm J Qual Patient Saf. 2007; 33:537-42.
7. Garber AJ, Moghissi ES, Bransome ED Jr et al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract. 2004; 10:77-82.
8. Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract. 2004; 10(suppl 2):100-8.
9. American Society of Health-System Pharmacists. Recommendations for Safe Use of Insulin in Hospitals. www.ashp.org/s-ashp/docs/files/Safe-Use-of-Insulin. pdf (accessed 2010 Feb 12).
10. Joint Commission. National Patient Safety Goals. www.jointcommission.org/ PatientSafety/NationalPatientSafetyGoals/08-hap-npsgs.htm (accessed 2009 Mar 3).
11. Joint Commission. The official "do not use" list. www.jointcommission.org/PatientSafety/DoNotUseList/ (accessed 2009 Mar 3).
12. Institute for Safe Medication Practices. ISMP's list of error-prone abbreviations, symbols, and dose designations. www.ismp. org/Tools/ errorproneabbreviations.pdf (accessed 2010 Feb 12).
13. Schnipper JL, Liang CL, Ndumele CD et al. Effects of a computerized order set on the inpatient management of hyperglycemia: a cluster-randomized controlled trial. Endocr Pract. 2010; 16:209-18.
14. Donihi AC, DiNardo MM, DeVita MA et al. Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin. Qual Saf Health Care. 2006; 15:89-91.
15. Schnipper JL, Ndumele CD, Liang CL et al. Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial. J Hosp Med. 2009; 4:16-27.
16. Noschese M, Donihi AC, Koerbel G et al. Effect of a diabetes order set on glycaemic management and control in the hospital. Qual Saf Health Care. 2008; 17:464-8.
17. Grissinger M. Reducing medication errors associated with intravenous insulin infusions. P&T. 2003; 28:628.
18. Pennsylvania Patient Safety Authority.
19. Institute for Safe Medication Practices. New color code for 25 gauge safety needles may lead to confusion and errors. ISMP Med Saf Alert. 2003 Mar 6.
20. Institute for Safe Medication Practices. Newsletter - acute care edition. May 8, 2008. www.ismp.org/Newsletters/acute-care/articles/20080508.asp (accessed 2009 Mar 12).
21. Food and Drug Administration. Information for healthcare professionals: risk of transmission of blood-borne pathogens from shared use of insulin pens. www.fda.gov/Drugs/DrugSafety/ PostmarketDrugSafetyInformationforPatientsandProviders/ DrugSafetyInformationforHeathcareProfessionals/ucm133352.htm (accessed 2010 Feb 12).
22. Greenwood B, Szumita PM, Pendergrass M. Conversion to insulin devices in the inpatient setting. Am J Health-Syst Pharm. 2008; 65:698-9. (Pubitemid 351555427)
23. Institute for Safe Medication Practices. PEN injectors: technology is not without imPENding risks. ISMP Med Saf Alert. 2006 Nov 30.
24. Pellissier G, Miguéres B, Tarantola A et al. Risk of needlestick injuries by injection pens. J Hosp Infect. 2006; 63:60-4.
25. Davis EM, Bebee A, Crawford L et al. Nurse satisfaction using insulin pens in hospitalized patients. Diabetes Educ. 2009; 35:799-809.
26. Davis EM, Christensen CM, Nystrom KK et al. Patient satisfaction and costs associated with insulin administered by pen device or syringe during hospitalization. Am J Health-Syst Pharm. 2008; 65:1347-57.
27. Institute for Safe Medication Practices. Insulin syringe is not meant for U-500 insulin. ISMP Med Saf Alert. 2001 Oct 17.
28. Browning LA, Dumo P. Sliding-scale insulin: an antiquated approach to glycemic control in hospitalized patients. Am J Health-Syst Pharm. 2004; 61:1611-4. (Pubitemid 39481406)
29. Hirsch IB. Sliding scale insulin - time to stop sliding. JAMA. 2009; 301:213-4.
30. Cohen MR, Smetzer JL, Tuohy NR et al. High-alert medications: safeguarding against errors. In: Cohen MR, ed. Medication errors. 2nd ed. Washington, DC: American Pharmacists Association; 2007.
31. Lien LF, Bethel MA, Feinglos MN. In-hospital management of type 2 diabetes mellitus. Med Clin North Am. 2004; 88:1085-105. (Pubitemid 39090351)
32. Institute for Safe Medication Practices. Action needed to prevent dangerous heparin-insulin confusion. www.ismp.org/Newsletters/acutecare/ articles/20070503.asp (accessed 2010 Jun 14).
33. Institute for Safe Medication Practices. Stop the insulin. ISMP Med Saf Alert. 2003 Sep 4.