title: Changes to medication-use processes after overdose of U-500 regular insulin.
abstract: OBJECTIVE
  Modifications made to medication-use processes after an overdose of U-500 regular insulin are described.
  
  
  CONCLUSIONS
  After a medication error occurred with U-500 regular insulin, a multidisciplinary team of physicians, nurses, advanced-practice nurses, and pharmacists was created to review and improve the ordering, dispensing, and administration processes associated with U-500 regular insulin. The group determined that current safety practices for managing insulin were inadequate. New safety processes specific to U-500 regular insulin were developed and implemented. Vials of U-500 regular insulin are no longer dispensed to nursing units and are stored only in the pharmacy and separated from other insulins. The ordering of U-500 regular insulin is limited to the endocrinology service, and all orders are written using a specialized U-500 regular insulin order set. The option for i.v. administration for U-500 regular insulin was removed from the pharmacy order-entry system; thus, only the subcutaneous route is entered by the pharmacist. In addition, patient-specific doses of U-500 regular insulin are prepared in the pharmacy using only tuberculin syringes that require a double check by two pharmacists. These syringes are delivered to patient care areas in a bag distinguishing the medication as "high alert." One last safety check involving a two-nurse check at the bedside to confirm correct medication administration is performed. Lastly, patient education material specifically for U-500 regular insulin is available online.
  
  
  CONCLUSIONS
  A multidisciplinary team recommended modifications to the medication-use system regarding U-500 regular insulin after review of a medication error. No errors involving U-500 regular insulin have been reported since implementation of the changes.
authors.affiliation: University of Texas M. D. Anderson Cancer Center, Houston, USA.
authors.forename: P Sayer
authors.initials: PS
authors.lastname: Monroe
authors.forename: Wendy D
authors.initials: WD
authors.lastname: Heck
authors.forename: Stacey M
authors.initials: SM
authors.lastname: Lavsa
mesh_terms: D000368:Aged; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D062787:Drug Overdose / Q000517:prevention & control*; D006801:Humans; D061386:Insulin, Regular, Human / Q000009:adverse effects*; D008297:Male; D008508:Medication Errors / Q000517:prevention & control*; D010348:Patient Care Team / Q000458:organization & administration; D010607:Pharmacy Service, Hospital / Q000592:standards*
chemical_list: D061386:Insulin, Regular, Human