Disasters Averted

From our partners at the Institute for Safe Medication Practices (ISMP): Organizations should strive to identify system-based causes of errors with the use of both insulin vials and insulin pen devices and implement effective types of error reduction strategies. Error reduction strategies such as constraints and standardization, which are more powerful …

From our partners at the Institute for Safe Medication Practices (ISMP): Most insulin products are supplied from the manufacturer in a 100 unit/mL concentration. The insulin is then administered using an insulin syringe specially designed for use with this concentration of insulin. When a patient needs a dose of 40 units, …

From our partners at the Institute for Safe Medication Practices (ISMP): Most pharmacy-generated labels, both in acute care and outpatient settings, display the name and strength (i.e., concentration) of the drug on the same line.

From our partners at ISMP: Among the wrong-dose insulin errors, 13.8% (n = 98) of the events involved breakdowns that occurred when transcribing orders, such as when entering orders into an MAR or a computerized order-entry system. Examples reported include the following….

There has been much written about problems with handwritten orders for insulin, including the use of dangerous abbreviations or dose expressions and other shortcuts when communicating orders. How the use of the letter “U” to abbreviate “unit” has contributed to medication errors has been discussed for several decades. Errors that …

From our partners at the Institute for Safe Medication Practices (ISMP): 

From our partners at the Institute for Safe Medication Practices (ISMP): 

From our partners at the Institute for Safe Medication Practices (ISMP), this week we have a review of IV Insulin Administration and two examples of what can go wrong when the correct procedures are not adhered to.

This week’s Disaster Averted comes courtesy of ISMP. There are numerous case reports in the literature that discuss the issue of wrong-drug medication errors with insulin products due to similarities in the brand and generic names, as well as similarity in labeling and packaging.11-14 Mix-ups have been noted between names occurring …

A 3-day-old infant weighing 1.3 kg was prescribed total parenteral nutrition containing 1 unit of regular insulin per each 327-mL bag.