Why do you think errors in insulin administration are one of the most common mistakes made in pharmacies and hospitals, and what can we do to prevent those errors?

this can make errors involving an improper dose or insulin type more likely. Also, unlike other drugs in hospitals, ordering and preparation of the dose may not involve the pharmacy, so an important independent check may not happen.

The frequency of administration also can lead to errors of omission (dose not given), and use of "U" for units of measurement can cause practitioners to misread the "U" for a number. In addition, there is confusing manufacturer labeling, a number of insulin products that have names that sound or look-alike, and a growing number of commercially available insulin mixes available and use of insulin pens in hospitals, which compound the likelihood of errors.

To reduce the likelihood of insulin errors, practitioners should design a preprinted order form or electronic order set for insulin that lists specific products, ingredients and component ratios, and have a pharmacy dispense doses wherever possible in order to take advantage of an independent system of checks. ISMP also recommends using only "units" and not "U" in insulin orders, and never using trailing zeros.

Problems associated with the use of insulin "pens," such as using a pen for more than a single patient, need to be addressed. Many other recommendations have appeared on ISMP's website or in our newsletters, and the Institute is planning a section on insulin safety for consumers on its consumer website (www.consumermedsafety.org).

If insulin is dispensed in vials, a pharmacy should label them for individual patients rather than supply them as a floor stock item but a process for retrieving discontinued vials must also be in place. Use of bar code scanning is recommended as well. Place reminders about potential confusion in computer systems and storage locations. Before making new or combination insulin products available, healthcare practitioners should conduct a failure mode and effects analysis to detect potential problems and take action before an error happens. Electronic medical records also afford the ability to print out current medications from the pharmacy computer to help prevent errors.