Reducing potentially fatal errors associated with high doses of insulin: A successful multifaceted multidisciplinary prevention strategy

BMJ Quality and Safety

Volumn 20, Issue 7, 2011, Pages 637-644

  Dooley, Michael J ^a,b   Wiseman, Meredith ^a,b   McRae, Amy ^a   Murray, Danielle ^c   Van De Vreede, Melita ^d   Topliss, Duncan ^b,e   Poole, Susan G ^a,b   Wyatt, Sue ^e   Newnham, Harvey ^b,f  

^a Pharmacy Department   (Australia)

^b MONASH UNIVERSITY   (Australia)

^c PETER MACCALLUM CANCER CENTRE   (Australia)

^d EASTERN HEALTH   (Australia)

^e NONE   (Australia)

^f General Medicine   (Australia)

Author keywords

[No Author keywords available]

Indexed keywords

INSULIN;

ADULT; ARTICLE; DRUG LABELING; DRUG MEGADOSE; HOSPITAL PATIENT; HUMAN; INSULIN TREATMENT; MAJOR CLINICAL STUDY; MEDICATION ERROR; PATIENT COMPLIANCE; PATIENT EDUCATION; PRACTICE GUIDELINE; PRESCRIPTION; PREVENTIVE MEDICINE; VALIDATION PROCESS;

GUIDELINE ADHERENCE; HUMANS; INSERVICE TRAINING; INSULIN; MEDICATION ERRORS; PRACTICE GUIDELINES AS TOPIC; QUALITY OF HEALTH CARE;

EID: 79959332066     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs.2010.049668     Document Type: Article

References (30)

1. Aronson JK. Medication errors: what they are, how they happen, and how to avoid them. QJM 2009;102:513-21.
2. Wilson RM, Runciman WB, Gibberd RW, et al. The quality of Australian health care study. Med J Aust 1995;163:458-71.
3. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84.
4. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6.
5. Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med 1993;8:289-94. (Pubitemid 23177840)
6. Anon. Australian Hospital Statistics 2008-09. In: Welfare AIoHa, ed. Health Services Series. Canberra: Australian Institute of Health and Welfare, 2010.
7. AIHW. Australia's Health 2010. Australia's Health Series. Canberra: Australian Institute of Health and Welfare, 2010.
8. Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 2007;147:755-65. (Pubitemid 351664440)
9. Anon. 33% of fatal med errors involve insulin therapy. Healthcare Benchmarks Qual Improv 2005;12:31-2.
10. Castledine G. Shouldn't the dangers of insulin be controlled better? Br J Nurs 2008;17:405.
11. Federico F. Preventing harm from high-alert medications. Jt Comm J Qual Patient Saf 2007;33:537-42.
12. James J. Insulin-treated inpatients and prescribing errors. (Review). J Diabet Nurs 2005;9:171-7.
13. Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract 2004;10(Suppl 2):100-8.
14. Kane-Gill SK, Kowiatek JG, Weber RJ. A comparision of voluntarily reported medication errors in intensive care and general care units. Qual Saf Health Care 2010;19:55-9.
15. Thompson R, Schreuder AB, Wisse B, et al. Improving insulin ordering safely: the development of an inpatient glycemic control program. J Hosp Med 2009;4:E30-5.
16. Sims J, Richardson T, Kerr D. Insulin errors in hospital: time for a radical re-think on risk? Clin Risk 2010;16:89-92.
17. 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.
18. Parmar MS. Four-digit insulin dosing code: a simple solution for insulin dosing error. Diabetes Care 2005;28:760-1. (Pubitemid 40315355)
19. Grissinger M, Kroon L, Penna P. Misadventures in insulin therapy: are your members at risk? J Manag Care Pharm 2003;9:2-9; quiz 10-13.
20. Ridge RA. Boosting insulin safety. Nursing 2007;37:14-15.
21. Clarke NR, Narendran P. Insulin prescribing is unsafe: education results in a significant but insufficient improvement. Diabet Med 2005;22:1779-80. (Pubitemid 43046488)
22. Santell JP, Hicks R, Protzel M. RN news watch: drug update. Error watch: is your patient a diabetic? Watch that insulin dose! RN 2003;66:92.
23. Cohen MR. Medication errors. Fatal insulin overdose: family matter. Nursing 1997;27:18.
24. Paparella S. Avoiding errors with insulin therapy. J Emerg Nurs 2006;32:325-8. (Pubitemid 44096725)
25. Quality Use of Medicines Program, Department of Health. Quality use of medicines alert: Subcutaneous insulin. December 2008. http://www.health.vic.gov. au/qum/downloads/insulin-alert.pdf (accessed 1 st Apr 2011).
26. Patient Safety and Investigations, Department of Health. Expanding the list of "never events". October 8, 2010. http://www.dh.gov.uk/prod- consum-dh/groups/dh-digitalassets/@dh/@en/@ps/ documents/digitalasset/dh-120270. pdf (accessed 1 st Apr 2011).
27. Phillips W, Lando H. Insulin confusion: an observation. Diabetes Care 2002;25:1103-4.
28. Wang SJ, Middleton B, Prosser LA, et al. A cost-benefit analysis of electronic medical records in primary care. Am J Med 2003;114:397-403. (Pubitemid 36513689)
29. Pearson DDR. Patient Safety in Public Hospitals. Victorian Auditor-General's Office, Victorian Government Printer, May 2008. http://download.audit.vic.gov.au/files/Patient-Safety-Public-Hospitals.pdf (accessed 1 st Apr 2011).
30. Lewis AW, Bolton N, McNulty S. Reducing inappropriate abbreviations and insulin prescribing errors through education. Diabet Med 2010;27:125-6.