b'Insulin Errors Potentially Plague Hospitals Treating Diabetes PatientsVA Has Had Problems Related to Insulin Pens, Concentrated DosesBy Brenda L. MooneyGuidelines from the Institute of Safe Medication Practices havewerehospitalizedbetween2012and pointed out that insulin is associated with more medication2013. 1TheVAshealthcaresystemhas errors than any other type or class of drugs. With more thannotbeenexemptfrominsulinerrors. 11,400 insulin-using veterans hospitalized in a recent two-yearInOctober2012,theVAWestern NewYorkHealthcareSystemchief period at the VA, that is an especially critical issue for theofpharmacydiscoveredthreeinsu-healthcare system. Intense focus on avoiding problems withlinpensdesignedforsingle-patient useonlywithnopatientlabelsin insulin, as well as new products, have improved the situation,a supply drawer of a medication cart. both with subcutaneous administrationsuch as insulin pens Facilityofficialssubsequentlyfound three more pens without patient labels and with intravenous insulin in the critical-care setting. in medication carts on three other inpa-tient units, and, when queried, several nurses reportedly acknowledged using the pens on multiple patients.HORSHAM,PAWithaquarterevidence to the high frequency of insu- Inareport,theOfficeofInspector ofveteranstreatedinVHAfacilitieslininvolvementinharmfulmedica- GeneralfortheVApointedoutthat havingadiabetesdiagnosis,VAMCstion errors. In 2004, a state reportinginappropriately using single-patient use deal with a high number of hospital- programestablishedthat25%ofallinsulin pens on multiple patients could ized patients requiring regular insulinreportedmedicationerrorsinvolvedpotentiallyexposepatientstoblood-administration. high-alertmedications,and16%borne pathogens.While the VA has instituted a num- involved insulin alone. Data publishedIn another, more-recent case, the VA ber of measures over the years to morein2008showedthatinsulinwastheis being sued over the death of a vet-safely administer insulin, especially inleading drug involved in harmful medi- eranfromawrongfulinsulininjec-inpatient settings, it continues to facecation errors, representing 16% of alltion at the Louis A. Johnson VAMC in a dramatically increased risk of medi- medication error events with reportedClarksburg, WV. The lawsuit filed ear-cal errors. Guidelines from the Instituteharm. A 2010 study found that the mostlier this year alleges a widespread sys-ofSafeMedicationPracticespointedcommon medical errors in critical caretem of failures at the facility. Federal out that insulin is associated with morepatientswereinsulinadministrationprosecutors, meanwhile, were reported medication errors than any other typeerrors. to have begun presenting evidence to or class of drugs. And, the number of veterans facinga grand jury in their criminal probe of As early as 1998, insulin was asso- those risks each year is large. A reportat least 11 deaths suspected of being ciated with 11% of all harmful medi- lookingatanotherissuetreatmentlinked to improper insulin injections at cationerrorsinhospitals,theISMPintensificationafterdischargenotedthat VAMC, which has not yet deter-explained.Morerecentstudiesaddthat11,430insulin-usingVApatientsmined whether the deaths were related 54 2020 COMPENDIUM OF FEDERAL MEDICINE'