A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
Improper insulin pen use is a persistent problem. This newsletter article reveals the lessons learned from one hospital that implemented best practices including robust education, bar-code scanning, bedside electronic medication administration records, and alerts to prevent incorrect administration but continued to experience errors related to insulin pen use.
Hall LW. AHRQ WebM&M [serial online]. October 2008.
Unexpected hypoglycemia in a critically ill patient.
Bates DW. Ann Intern Med. 2002;137:110-116.
Computerization can create safety hazards: a bar-coding near miss.
McDonald CJ. Ann Intern Med. 2006;144:510-516.
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The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study.
Franklin BD, O'Grady K, Donyai P, Jacklin A, Barber N. Qual Saf Health Care. 2007;16:279-284.