NCPS: Taking Aim at Medication Errors, Question 3

The care of the diabetic patient and the associated use of medications, including Insulin, have been identified as high vulnerability areas. One way we facilitate sharing actions designed to increase patient safety VA-wide which have been identified during local root cause analysis, is to prepare topic summaries. I have attached the topic summary, I completed on diabetes. The summary identifies system vulnerabilities, actions taken to mitigate, strength of action based on human factors engineering principles and how the local facility rated the outcome of their action. We also use VA-wide Alerts and Advisories to mandate specific actions be taken by VA Medical Centers to mitigate identified safety issues.

Question 1

Question 2

Question 3

Question 4

PDF Patient Safety Alert: Insulin U-500 Safety Enhancements (March 2009)

PDF NCPS: Diabetes and Insulin Management Topic Summary

For more general information on preventing, catching and reporting errors, see our Safety and Error Prevention page.