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It is painfully obvious that we are as yet nowhere near a solution, even for the so called “high alert” medications! According to the 2006 Institute of Medicine Report “Preventing Medical Errors,” on average, a hospitalized patient is subject to at least 1 medication error per day, with at least 1.5 million preventable adverse drug reactions occurring each year. According to an analysis of over 73,000 intravenous drug errors reported to the US Pharmacopoeia MedMarx database between 2000 and 2004, more than 50% of errors were in the process of actually administering medications, and 60% of these errors occurred in the intravenous administration of 1 of 20 “high alert” medications (Table 1). In order to save lives and prevent harm to patients, far reaching changes are needed in the way medications are prepared and administered. Representatives of these and other national organizations joined in an intensive 2-day Intravenous Safety Summit convened by the American Society of Health System Pharmacists (ASHP) in Rockville, MD, on July 14-15 to recommend very specific and attainable changes in practice that will be effective in preventing medication errors and saving lives now lost to adverse drug events. Simplifying the administration process, with preference for the preparation of intravenous medication in the pharmacy rather than at the point of care. Obtaining the maximum benefit from technology in the form of bar codes, computerized order entry, and smart pumps. The specialty of anesthesiology and the practice of nurse anesthesia are both in very good positions to take leading roles in research, practice changes, and cultural changes needed to save lives now lost due to medication errors. Establishing a “culture of safety,” however, may be more difficult than developing technology.
Therefore, as a very important next step, the Anesthesia Patient Safety Foundation is planning a Board of Directors’ Workshop for Friday, October 17 in Orlando, FL, entitled “Innovations in Medication Safety in the Operating Room.” The workshop is designed to identify solutions for medication errors in the operating room that are currently technologically feasible, as well as ideas for potential new processes to be developed and explored. An acute prescription is one which has (usually) been given as a one-off and is not intended to be given again and again. Repeat prescriptions – as detailed in the practice leaflet, all prescription requests will be ready within 48 hours (2 working days). Medication Request –  the patient later requests the repeat medication either via the repeat script (preferred), electronically or via telephone.
Prescription storage – admin staff place the prescription in a secure holding area until patient arrives to pick it up.
When prescribing a new repeat, try and syncronise – match up all repeat medications in terms of quantities (that it runs out when other medication runs out) and review dates.
Staff need to be very careful with requests for repeat medication via e-mail or the internet. Remember that telephone requests for medication can  (i) block more urgent calls, (ii) block patients trying to make appointments, (iii) distract receptionists whilst processing requests, and  (iv) lead to one request not being processed before the next telephone call is answered. The Practice Manager will check that the computer is set so that compliance issues are flagged and a message over ridden before the receptionist can continue.
Medicines which can be taken on a ‘when required’ basis may be flagged by the computer as being underused e.g. If the review date is approaching, the item can be issued and the patient informed that a review appointment is due e.g. Repeat prescriptions need to be prepared with accuracy by a receptionist who is trained up in the role of repeat prescribing.
In order to reduce the risk of mistakes, the receptionist who has the task of processing the repeat prescriptions should do so in a quiet area where they can concentrate and not be distracted. Prescriptions need to be printed and processed within 48 hours of recieving the request from the patient.  When accepting a request from a patient for a repeat prescription, please tell them that the turnaround time for a prescription will be 2 days and that they should not come to collect it before then.
Provide a record of the issue in the patients notes – so that others can see what has been given. Provide the patient with a copy of the items that have been authorised as a repeat prescription, which can be used to request a repeat. Can be used as a source of data and audit to improve prescribing quality and maximise cost effectiveness. Does the drug continue to be effective – is it having the desired effect, are they on the right dose?  Is there a better and more suitable alternative? Determining which medicines are being taken and deleting any medicines which are not being ordered and duplicate medicines.  It is good practice to periodically run searches to determine which medications are not being ordered. All repeat medications must be commenced on the computerised patient repeats prescription list by a GP and authorised for a set number of issues.
Normally the review date for stable medicines is set at 12 months but it should be set earlier for patients who should be seen more often (e.g. The review date acts as a safety mechanism to ensure that medicines are flagged back to the prescriber for review.
The review date should be the same for all the medicines (except those where a particular medicine may need an earlier review). An entry needs to be made in the medical records at the time of medication review to indicate that it has occurred, noting any changes. Once prescriptions are signed, they should be stored in a secure area away from public access.  In Ashcroft Surgery, there is a prescription filing cabinet in the receptionists area (which is partitioned off from the patient waiting area). Queries about a medication (for example, if the patient asks about side effects or interactions with other drugs or asking for a medication to come off their repeat list).
Our Practice Manager will ensure that staff will only have functions on their smart cards which are appropriate to their specific role.
All scripts requiring a doctor’s agreement and signing will be placed in the ‘prescription’ tray in the reception room. From 0830, any new prescription requests from 0830 until 2pm should be put into the emptied prescription tray.
At 2pm empty this tray and distribute the prescriptions across all the GPs doing surgeries – put them in their individual prescription trays and place them by their keyboards.
After 2pm– Those those that have been collected should be put in the emptied prescription tray, ready to dish out to the working GPs the next following morning.  Remember, only to distribute to GPs doing surgeries, not GPs who are working but doing something else like medical student or gp-trainee tutorials. The Doctors must deal with all scripts during or at the end of their clinical session and return them to the admin ‘signed scripts’ tray.
If the prescription is not needed urgently, ask them to present their completed request form. Do issue this time, but explain that this is a one-off favour to them and update the screen message (i.e. Returned request forms should be given to the Practice Manager who will confirm the authorisation in writing to the patient. Patients should only be ringing for repeat prescriptions during 2-4pm on Tuesdays, Wednesdays and Fridays.  If they ring outside these periods, deal with their query as a one-off and advise them of the correct times. Confirm that the patient is authorised by looking for code & description in Active Problems list. Confirm to which chemist – if they want to collect it or get it collected by a friend or relative, then politely ask them why this not done to deliver the repeat slip.
Telephone Number (on which to be contacted should the prescriber refuse to issue the request).
And finally, remember that some of these patients might benefit from email us their required repeats rather than telling us over the phone – so advise them as appropriate to their abilities and resources.
Try to ensure any prescriptions you have promised to provide are signed before you complete your shift or passed onto another member of staff for their overview.
Tell the patient that you cannot see it on their usual set of repeat medicines and ask them politely why they are making the request.
Advise them that you can see it on their acute list but ask them whether they know if the doctor planned to give it as a one-off or as something to be taken regularly. If the patient says it was meant to be a repeat, pass onto the doctor with a note asking if it should be on a repeat. Tell them that drugs not given by the doctor cannot be given without the doctor assessing them first. Patient should see or talk with a GP for a decision on whether to give the medication or not.
And that urgent requests like these result in interrupting the doctors who are already busy seeing ill patients.
And that urgent requests like these create unnecessary chaos for the practice who already have much to do. Try to ensure that any prescription you have ‘promised’ is signed & available for collection before the end of your shift or agree with another member of staff for them to oversee it. Doctor to check review date is accurate – for example, has a review been done but date not reset? Try to find out why the patient is asking for more medication before the expected time  – ask the patient. If ordering very early (and no explanation is available) do not issue but put clear message on screen.  Again, contact the patients as to why they are asking for it so early.
Then issue the prescription but bring it to the attention of the GP with a note on the prescription saying ‘Under-using’  and give the reason for the underusage if you have managed to determine it through talking with the patient. If it is a replacement request, the patient needs to contact the Air Products oxygen cylinder provider direct with whom that should have been authorised with via the HOOF process. ABSTRACTControlling blood sugars with insulin is essential in the management of hyperglycemia in both diabetic and nondiabetic patients. Documentation is an integrated component of the process of developing a nursing care plan that is initiated by the appropriate nursing personnel. For demonstration purposes, the abbreviated medical history below is appropriate for all examples (Figs.
Figure AppD-1A addresses the three major NANDA diagnoses, which are numbered in the NANDA Diagnosis column.
Each NANDA diagnosis would be addressed separately using the APIE format based upon the nursing assessment, the care plan, and the NANDAs. With charting by exception, the nurse generally starts by working with a standard systems flow sheet (Fig.
Figure AppD-5 shows a graphic flow sheet that indicates multiple areas of routine charting. FIGURE 2 · Example of problem area (focus) charting: SOAP (subjective, objective, analysis, plan). FIGURE 3 · Example of problem area (focus) charting: APIE (assessment, problem, implementation, evaluation).

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However, partly because of the huge number of doses and the number of different medications given daily, errors in IV medication administration still represent a significant health care problem in the United States today.
The administration of flush solution with a heparin concentration 1000-times that intended to 17 Texas neonates in Corpus Christi on July 4 this year is just one very recent example of how far we have to go. These reactions lead to an estimated $3.5 billion in additional health care costs annually to hospitalized patients alone, and reactions to drugs represent between the fourth and sixth leading cause of deaths in hospitalized patients. However, 5% occurred in the operating room or in the pre- or post-anesthesia care units, where anesthesiologists and nurse anesthetists routinely practice. The persistence of the problem has led to a new sense of urgency on the part of many organizations dedicated to patient safety, including the Institute of Medicine (IOM), the Institute for Safe Medical Practice (ISMP), Emergency Care Research Institute (ECRI), Joint Commission, Food and Drug Administration (FDA), Centers for Medicaid and Medicare Services (CMS), National Patient Safety Foundation (NPSF), United States Pharmacopeia (USP), Agency for Healthcare Research and Quality (AHRQ), the Institute For Healthcare Improvement (IHI), the National Quality Forum (NQF), and many other professional and specialty organizations.
One of the real strengths of this summit was the integral involvement of frontline practitioners—nurses, physicians, and pharmacists, as well as vendors, health system experts, and researchers.
Anesthesiologists are one of the few groups of physicians who are personally responsible for drug administration. Stabile, Webster, and Merry, in the Fall 2007 issue of the Anesthesia Patient Safety Foundation Newsletter, called for just such a cultural shift in medicine, from a culture of productivity to a culture of safety. Participants in this workshop will include physicians, pharmacists, health systems and technology researchers, as well as representatives from the Joint Commission and other regulatory agencies. Martin is Professor of Anesthesia at Penn State University College of Medicine in Hershey, PA. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. A new, safety-oriented, integrated drug administration and automated anesthesia record system.
Evaluation in an anaesthetic simulator of a prototype of a new drug administration system designed to reduce error. Patients should be advised at the time of request that the doctor may wish to see them before the item is issued.
This does not mean that patients telephoning outside these hours should be refused medication, instead the request should be accepted and the patient reminded of the designated times when requests should be made. There is evidence to suggest that on screen reminders are more effective than feedback in modifying behaviour related to medicines management. If the prescription states ‘when required’ then a maximum dose needs to be stated.   MDU or ‘as directed’ are not acceptable. Explain to them that their immediate request puts unnecessary pressure on the practice because it interrupts GPs who are busy attending to patients. However, studies have shown that the use of insulin has been associated with more medication errors than any other type or class of drug. Computerized templates of forms or hard copy pen-and-paper preprinted forms can be used, depending on the individual facility needs, resources, and requirements. The documentation is written as a narrative as the events occurred (ie, narrative chronological charting).
For instructional purposes using this example, the NANDA diagnoses are also in bold italics within the charting. At the time of the collection of data, the nurse also discovers significant abnormal findings related to nausea, abdominal distention, and pain.
AppD-4A), which indicates most normal findings according to body system (neurologic, cardiovascular, and so forth) or other organized, preprinted format. Gastrointestinal tissue perfusion ineffective related to mechanical blockage of peristalsis as manifested by hyperactive bowel sounds RUQ, absent bowel sounds in remaining quadrants, and acute, severe abdominal pain and nausea.
Birdy to pay the salary within 7 offer office offset overtime paid pay payment payout penalty performance . It has been almost 9 years since the Institute of Medicine’s Report “To Err is Human” shocked the public consciousness and the medical establishment in 1999.1 Since then, much has been said and written about the problem, and there have been some significant steps forward.
In the operating room, it has been estimated that 1 drug administration error occurs for every 133 anesthetics.2 Approximately 1% of these errors actually cause patient harm. Historically, our specialty has been able to effectively design monitors and ventilation systems and to greatly reduce death due to hypoxia or ventilatory failure in anesthetized patients. In their words, “safety should be funded because it is the right thing to do, not because of any ROI directives.” Commercial aviation and other similarly complex yet high-risk industries adopted a culture of safety years ago. The very practical solutions coming from this workshop, as well as the ASHP IV Medication Safety Summit may well provide the innovations in drug administration processes, as well as insight into the human factors responsible for inevitable human errors, which are needed to bring about a true reduction in medication errors in the operating room. Staff who process repeat prescriptions should be aware that this is acceptable although should still be brought to the doctors attention. Give message to the reception staff to ask patient to make appointment for Medication Review.
Explain that on this one occasion we will do them a favour but it still will involve a significant wait. From January 2008 to June 6, 2009, Pennsylvania healthcare facilities submitted 2,685 event reports to the Authority that mentioned medication errors involving the use of insulin products. Nursing diagnoses (NANDAs) are integral parts of the nursing process and need to be reflected in your facility’s documentation and record-keeping formats. The NANDA diagnoses are developed from this medical history and from an initial comprehensive admission nursing assessment, which is not provided here. Notice  how the numbered NANDAs, from the abbreviated medical history above, are integrated into the assessment. Other ways of documenting charting errors are to write recorded in error or mistaken entry and your initials.
The Joint Commission has made reduction of medical errors one of its national patient safety goals for the past several years.
Therefore, elimination of medication errors represents a tremendous opportunity to save lives and improve patient care in the OR as well as in the remainder of the hospital.
Anesthesiologists already have effective patient safety, “standards,” and “practice advisory” infrastructures in place.
The practice should develop their own list of medicines which they feel are acceptable to be under-used.
If any blood tests are required give clear message to the receptionist to book these prior to the review and note in consultation record which bloods are required. The basic nursing process consists of the assessment, identification of NANDAs, plans with specific goals, interventions or implementations, and the evaluation of each plan or goal. In 2006, the FDA mandated that manufacturers include a machine readable bar code on the label of the containers of many prescription drugs.
Significant research has already been done to evaluate drug administration procedures and technology to improve safety of drug administration during anesthesia (Table 2).
However, trade names can vary from country to country and is often given by the company that makes that drug.
Her history includes a cerebrovascular accident 2 years ago, resulting in weakness of the left leg.
New technology such as bar codes, radio frequency identification (RFID), and computerized order entry (CPOE) systems have all come on the horizon as technological solutions, only to create different problems which may be almost as big as those they are intended to solve. Sins, MD, represented Partners Healthcare and brought unique expertise in the emerging “smart pump” technology. All of these improvements have a potential to improve the process of drug administration in the operating room, which is a complex collection of more than 40 steps, if used to enable anesthesia providers to work more safely, as well as more quickly and efficiently. Strategies to address these problems include limiting the variety of insulin products on the organization’s formularies, developing standardized protocols and a standard format for prescribing insulin, avoiding the use of abbreviations or other shortcuts when communicating orders for insulin, and requiring an independent double check of all doses before dispensing and administering intravenous insulin. She was admitted to the acute care facility 2 days ago with a diagnosis of left lower lobe pneumonia. In this example, the patient might ask for Zantac, but on their repeat prescription, it will be listed as Ranitidine.
For example, it is used to manage hyperglycemia in intensive care unit (ICU) patients, a common finding caused by insulin resistance in the liver and muscle tissue.
Some have considered insulin resistance to be an adaptive response, providing glucose for the brain, red blood cells, and wound healing.3 Due to a number of conflicting published studies, there has been an increased effort to determine the benefit of tightly controlled blood glucose levels, both in diabetic and nondiabetic patients. For example, in a large, single-center study of postoperative surgical patients, an initial investigation by van den Berghe et al. Patients receiving intensive insulin therapy were found to be less likely to require prolonged mechanical ventilation and intensive care.
The NICE-SUGAR study also demonstrated that there was no significant difference between the two treatment groups in the median number of days in the ICU or hospital or in the median number of days of mechanical ventilation or renal-replacement therapy.
In a meta-analysis of randomized controlled trials of tight glucose control versus usual care in critically ill adults, the authors found no significant difference in hospital mortality or new need for dialysis. Although tight glucose control was associated with a significant reduction in septicemia overall, subgroup analysis suggested this benefit was limited to surgical ICU patients. Conversely, they found clear evidence that hypoglycemia increased roughly fivefold, regardless of the ICU setting, and was more common with patients receiving very, rather than moderately, tight glucose control.6For many years, literature has shown that the use of insulin has been associated with more medication errors than any other type or class of drug. This imprecise data collection limits individual facilities and the Authority from accurately determining the most common pairs of insulin products involved in wrong-drug errors. In addition, many of these reports did not specifically state why the error occurred or what went wrong that led to the patient receiving the wrong insulin product.

Analysts were able to determine the following:Seventy-five (20%) reports of wrong-drug insulin errors specifically mention that the breakdown occurred when retrieving the medication, for example, from stock or an automated dispensing cabinet (ADC).
Specifically, 28 reports (37.3% of stock errors) mentioned the use of overrides to obtain the insulin product from an ADC. Sixty-five (17.4%) reports of the wrong-drug events specifically identified that the error occurred during the prescribing node. When the physician came in the following day, the order was clarified, and he ordered Novolin N insulin.
Unless this infusion is distinguished with highlighting or a prominent sticker, an insulin infusion will resemble other pharmacy-prepared infusions. Of the wrong-drug errors involving insulin reported to the Authority, infusion bags containing insulin were mentioned in 9.4% (n = 35) of the cases. Examples are as follows:An IV insulin bag was hung when replacing the patient’s Versed® (midazolam) bag. Two bags of insulin were then hanging, one at rate of 8 (Versed rate) and one at 5 (insulin rate). The wrong-bag error was found at [the next] change of shift.A patient was ordered IV Lasix® (furosemide), as well as IV insulin. The nurse meant to hang the IV Lasix but [before midnight] hung a bag of IV insulin instead. Both IV drips were turned off at that time, and the patient was given 50 ml of 50% dextrose. Four hours later, the oncoming RN was checking and verifying the patient’s IV drips and discovered the error. For example, correction doses, sometimes referred to as “coverage” or erroneously as “sliding scales,” are used to adjust glucose levels around mealtimes. Organizations often have multiple algorithms for corrections doses, such that a facility may have “low dose,” “medium dose,” and “high dose” algorithms that require the nursing staff to obtain and document each patient’s blood glucose reading, determine the patient’s ordered algorithm, and then select the proper dose based on the blood glucose reading.The predominant theme mentioned in reports of wrong-dose events involves the dosing of insulin based on a range of blood glucose values with a corresponding coverage dose, determined by a patient’s blood glucose reading.
Of the wrong-dose errors submitted to the Authority (n = 712), 26% (n = 185) mention coverage or sliding scales.
While this term may be used in place of “correction dose” or “coverage,” it should be noted that sliding-scale insulin regimens used alone are ineffective and potentially harmful. When using subcutaneous insulin injection therapy, scheduled or standing insulin regimens should be the standard of care.18-21) As mentioned previously, this recommended method of maintaining tight control of a patient’s blood sugar, regardless if the patient is diabetic or not, adds complexity to the medication-use process for all healthcare practitioners. Adding to the complexity of these orders are the multiple values often used for multiple ranges of blood sugars. Problems have also occurred when shortcuts are taken when writing these types of orders for insulin. For example, orders have been written stating doses of insulin as “6+1” or “6+2” instead of writing out “7” or “8” (see Figure 1).   Figure 1.
Errors also have occurred when selecting the blood glucose range, dose, or algorithm from a pharmacy label, a handwritten MAR, or a computer-generated MAR (see Figure 2). Pennsylvania facilities are experiencing these types of errors as evidenced by these events reported to the Authority:A patient was ordered insulin on sliding scale level 2, but the order was transcribed incorrectly on the MAR as sliding scale level 1. Order was transcribed onto medication sheet as bedtime coverage, but original order was for no bedtime coverage. The chart was reviewed due to the very high dose of Novolog to be given, and it was found that the 5 was crossed off. Although writing out the complete word “units” is the recommended alternative to using the abbreviation “U,” be aware that tenfold overdoses may still occur when writing the word “unit(s),” particularly when there is inadequate white space between the dose number and the word (see Figure 3). Examples reported to the Authority include the following:A patient was admitted to the ED [emergency department] after [the patient’s] morning insulin had been administered. The patient was transferred, and the nurse administered the evening dose of Lantus 70 units as ordered, with appropriate double check. The nurse increased tube feedings, and subsequent accuchecks were read as “error.”The physician transcribed an incorrect insulin dose from the transfer orders. The physician misinterpreted the order due to the fact that the u (for units) was very close to the 7 on the transfer orders.   Figure 3. Order Written for 8 Units of Lantus Insulin Misread as 80 UnitsTranscribing and Order-Entry ErrorsAmong 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 to the Authority include the following:A patient was ordered “human regular insulin 150 units subcutaneously qam prn,” with the reason stating that the patient was on the medication at home. The first blood sugar parameter was incorrectly entered by the [physician] as the insulin dose.A physician wrote an order for a patient to receive four units of regular insulin if the patient’s early morning blood sugar was equal to or greater than 250. Specific problems reported to the Authority included reporting an incorrect value, confusing the patient’s weight for his or her blood glucose level, and communicating the wrong patient’s value, as well as simply documenting the wrong result. Both licensed professionals and support staff have been involved in these breakdowns.The patient’s blood sugar was written on the board as 148. When the nursing assistant wrote the Accuchecks on the bulletin board, the blood glucose of 97 was written for that patient. The nurse used the wrong number for the coverage, using the patient’s weight of 341 pounds, when the BG was 81. The nurse’s aide gave her the wrong number.A nurse extern came out of patient’s room at the time accuchecks are performed.
The nurse covered the patient with four units of regular insulin when five minutes later nurse extern informed the RN that the patient’s blood glucose level was 130. In a similar example reported by the Institute for Safe Medication Practices (ISMP), a nurse picked up a piece of scrap paper that listed several patients with a number next to each name.23 All of the numbers were well above 200. Assuming the numbers were blood glucose results, she administered insulin to each patient using a sliding scale protocol. Similarly, pharmacy-provided, computer-generated MARs and other forms of drug information display dosage strength or concentration information the same way as the label. Although this issue was only apparent in 14 events reported to the Authority, it is of great concern because of the potentially large difference between the intended dose and the administered dose.Patient was on Lantus insulin at the nursing home. The patient’s blood sugar was 85 [that evening], so this dose was not given, and it was subsequently decreased to 80 units. The patient did receive the 80 units the next day, and the blood sugar dropped to 52 two days later. The Lantus dose was decreased again to 40 units on the following day and was administered at bedtime. When I saw these medications ordered for [the evening dose], I questioned the patient on the amount of Lantus he takes at home.
I asked how much he had last night, and he said the nurse brought in a large syringe full of insulin.
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, a caregiver draws the insulin to the designated 40-unit marking on the insulin syringe. For example, a patient using U-500 insulin with a U-100 syringe might state his dose as “40 units” because he is reading 40 units on the U-100 syringe he used to administer the insulin.
However, he is actually administering 200 units of insulin because of the higher concentration. This increases the risk that a fivefold dosing error will occur when the patient communicates his dose to a healthcare practitioner. The Authority’s database includes the following examples:A patient was admitted on routine regular insulin, and sliding scale was ordered at admission.
The pharmacist modified the insulin orders with additional signature of the patient’s own medications. The regimen ordered was Humulin R 85 units before lunch, 70 units before breakfast, 95 units before supper, and 35 units [at bedtime]. Wednesday after D50W administration and eating breakfast.U-500 insulin was prescribed as units (from a U-100 syringe) instead of volume.
A call was made to the physician to ask about changing to U-100 insulin for more accurate measurement.
He simply thought it would be easier for the nurses if he prescribed 25 units knowing that the “25 units” marking on a U-100 insulin syringe scale would actually measure 125 units when U-500 insulin was used. In another case, a physician changed a patient’s insulin to U-500 and prescribed 5 units at noon and 8 units at dinnertime. As in the first case, the doctor meant for the nurses to use a U-100 syringe when preparing and administering the U-500 insulin. Thus, he intended the patient to receive 25 units at noon and 40 units at supper.25 Problems also arise with the vials on nursing units.
One case involved a vial of U-500 insulin that was left in a nursing unit refrigerator after the patient for whom it was prescribed went home.26 While looking for regular insulin in the refrigerator, a nurse saw the familiar brand name, Humulin R (regular insulin) but did not notice the U-500 concentration. Luckily, another nurse saw the vial that was used and noticed that the U-500 insulin was given in error—a fivefold overdose.Risk Reduction StrategiesOrganizations 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 because they focus on systems, will be more effective than education alone, which relies on individual performance and will likely be ineffective when used alone.Constraints Organizations should use strategies that lessen the chance of harm with the use of insulin. If a nonstandard insulin concentration is needed, list the concentration and the patient’s dose in units and volume.29 Establish a plan for treating hypoglycemia for each patient. Apply bold labels on atypical insulin concentrations.27RedundanciesFor example, require an independent double check of all doses before dispensing and administering IV insulin. Sample strategies include the following:Nurses need to know patient’s blood glucose level before administering insulin. Prevalence of Diagnosed and Undiagnosed Diabetes in the United States, All Ages, 2007 [online].

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