NCPS: Taking Aim at Medication Errors, Question 3

SF: What are the most common errors that occur at the VA in regards to diabetes patients and what has the VA done to prevent them from happening again?

KT: The data found within NCPS SPOT data is voluntarily reported so it is not a good indicator for prevalence of safety incidents. As I had mentioned, it can be used for identifying trends in incidents [Diabetes and Insulin Management Summary (including system vulnerabilities and suggested solutions) pdf attached]….

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.