title: Reduction of medication errors related to sliding scale insulin by the introduction of a standardized order sheet.
abstract: Insulin is frequently used for glycemic control. Medication errors related to insulin are a common problem for medical institutions. Here, we prepared a standardized sliding scale insulin (SSI) order sheet and assessed the effect of its introduction. Observations before and after the introduction of the standardized SSI template were conducted at Gifu University Hospital. The incidence of medication errors, hyperglycemia, and hypoglycemia related to SSI were obtained from the electronic medical records. The introduction of the standardized SSI order sheet significantly reduced the incidence of medication errors related to SSI compared with that prior to its introduction (12/165 [7.3%] vs 4/159 [2.1%], P = .048). However, the incidence of hyperglycemia (≥250 mg/dL) and hypoglycemia (≤50 mg/dL) in patients who received SSI was not significantly different between the 2 groups. The introduction of the standardized SSI order sheet reduced the incidence of medication errors related to SSI.
authors.affiliation: Department of Pharmacy, Gifu University Hospital, Yanagido, Gifu, Japan.
authors.forename: Saki
authors.initials: S
authors.lastname: Harada
authors.affiliation: Department of Pharmacy, Gifu University Hospital, Yanagido, Gifu, Japan.
authors.forename: Akio
authors.initials: A
authors.lastname: Suzuki
authors.affiliation: Department of Pharmacy, Gifu University Hospital, Yanagido, Gifu, Japan.
authors.forename: Shohei
authors.initials: S
authors.lastname: Nishida
authors.affiliation: Department of Pharmacy, Gifu University Hospital, Yanagido, Gifu, Japan.
authors.forename: Ryo
authors.initials: R
authors.lastname: Kobayashi
authors.affiliation: Patient Safety Division, Gifu University Hospital, Yanagido, Gifu, Japan.
authors.forename: Sayuri
authors.initials: S
authors.lastname: Tamai
authors.affiliation: Patient Safety Division, Gifu University Hospital, Yanagido, Gifu, Japan.
authors.forename: Keisuke
authors.initials: K
authors.lastname: Kumada
authors.affiliation: Patient Safety Division, Gifu University Hospital, Yanagido, Gifu, Japan.
authors.forename: Nobuo
authors.initials: N
authors.lastname: Murakami
authors.affiliation: Department of Pharmacy, Gifu University Hospital, Yanagido, Gifu, Japan.
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Itoh
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001786:Blood Glucose; D002985:Clinical Protocols; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000517:prevention & control*; D007003:Hypoglycemia / Q000517:prevention & control*; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D007328:Insulin / Q000008:administration & dosage*; D008297:Male; D008508:Medication Errors / Q000517:prevention & control*; D008875:Middle Aged; D012189:Retrospective Studies
chemical_list: D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin
keywords: communication failure; medication error; sliding scale insulin; standardized order sheet