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ADDRESS:
Patient Safety Authority
333 Market Street
Lobby Level
Harrisburg, PA 17120


Phone: 717-346-0469
Fax: 717-346-1090


  
Educational Tools 
Insulin Therapy 
Insulin Therapy 

In events involving insulin reported to the Pennsylvania Patient Safety Authority, more than half led to situations
in which a patient may have or actually received the
wrong dose or no dose of insulin, which could lead to difficulties in glycemic control. Strategies to address these problems include limiting the variety of insulin products, developing standardized protocols and a standardized prescription format, avoiding the use of abbreviations, and requiring an independent double check of all doses before dispensing and administering intravenous insulin.
 

 Educational Resources
Insulin Measures Worksheet
This sample worksheet may be used for documenting facility-specific process and outcome measures involving the use of insulin.

 Articles
Medication Errors with the Dosing of Insulin: Problems across the Continuum
In reported events involving the use of insulin products, 52% of the events led to situations in which a patient may have or actually received the wrong dose or no dose of insulin.
Spotted Again: Insulin/TB Syringe Confusion
An event report about insulin and tuberculin syringe confusion prompts revisiting this topic, which was first highlighted in the October 28, 2004, supplementary Advisory.
Complexity of Insulin Therapy
Nearly 16% of Serious Events submitted through PA-PSRS involved the use of insulin, a high-alert medication.
Follow-up on Previous Advisory Articles
Patient Safety Officers share feedback and follow-up on two topics of previous Advisory issues (i.e., insulin and tuberculin syringe confusion, time out processes).
Overdoses Caused by Confusion Between Insulin and Tuberculin Syringes
Errors in which tuberculin syringes were used in place of insulin syringes may be attributable to a resemblance in packaging of the two syringes.
 
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