b'to a mistake or an intentional act by a former nursing assistant. The veterans, many of whom did not have diabetes, died of hypoglycemia.According to the earlier OIG report on insulin pen misuse, the United States Pharmacopeia described 4,764 insulin errors over a two-year period that were reportedtotheirvoluntaryreporting program.Ofthose,6.6%resultedin patient harm, while, in another study, Tufts-NewEnglandMedicalCenter conducted an analysis of adverse events involvingglucoseloweringagentsat 21 healthcare organizations and deter-minedthat,overaboutathree-year period, 2,125 inpatient errors involving insulin had occurred.In its guidelines, the ISMP pointed out the following problems associated with Hospitals regularly test blood glucose levels in patients with diabetes but treating high blood sugar with insulin dispensing, administering and monitor- too often results in medical errors.ing subcutaneous insulin: Intermediate and long-actinga significant challenge often not Lack of prospective risk subcutaneous insulin doses are notbeing met in inpatient settings.assessment to identify patients dispensed in the most ready-to-useIn two studies, less than half ofat high risk for hypoglycemia. form in inpatient settings, so thatpatients met the goal of receivingEstablishing and maintaining often the wrong vial of insulin isa rapid-acting insulin withinclinically appropriate glycemic selected from unit stock and the10-15 minutes of a meal, andtargets in both the inpatient and wrong dose of insulin is measured35% received glucose monitoringoutpatient settings has been when withdrawing it from a vialwithin one hour prior to insulindifficult, because the risk of into a syringe. administration. hypoglycemia increases withErrors with communicating andtighter glycemic control.measuring doses of concentrated Lack of protocols to guide insulin insulin. Most of the reportsadministration. One type ofc oncenTraTedi nsulinhave been related to dosingerror seen in the absence of suchConcentrated insulin doses can be es-confusion caused by the previousprotocols is the withholding ofpeciallyproblematic.Thenational unavailability of a syringe witha basal dose of insulin when aepidemic of diabetes and the exposure a U-500 scale. This requiredpatients glucose is within normalof Vietnam veterans to Agent Orange practitioners to measure U-500limits at the time a dose is due. hasledtoinsulinresistancerequir-doses with a U-100 syringe or No standardized process foring concentrated insulin (U-500 regu-tuberculin syringe and to teach thealerting physicians, pharmacistslar[U-500R]insulin)forglycemic patient how to communicate theirand nurses as to when insulincontrol,VAPittsburghHealthcare doses in syringe units. doses must be adjusted, held orSystemresearcherswroteinastudyCoordinating glucose monitoring,discontinued based on changes intwo years ago. 2meal delivery and insulinthe patients carbohydrate intakeIn their report in the journal Clinical administration within the ideal time(e.g., changes in enteral feedings,Diabetes,thestudyteamdescribed frame for rapid-acting insulin isparenteral nutrition, NPO status).howtoovercomepotentialhealth 2020 COMPENDIUM OF FEDERAL MEDICINE 55'