Prescribing errors in diabetes have the potential to cause serious adverse effects. Antidiabetic agents are a significant cause of admission to hospital. Prescribing errors can be caused by poor handwriting, failure to communicate clearly, and by the use of inappropriate abbreviations. Serious errors involving insulin have been reported in the UK media. While education and training may reduce the number of errors, experience shows that errors will continue to occur without changes to systems.Br J Diabetes Vasc Dis 2009;9:84—88
Kohn LT, Corrigan JM , Donaldson MS (eds.). To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press, 1999 .
2.
Department of Health.An Organisation With A Memory. London: Department of Health, 2000.
3.
Ferner RE, McDowell SEDoctors charged with manslaughter in the course of medical practice, 1795-2005: a literature review. J R Soc Med2006:99:306-14.
4.
Lewis PJ, Dornan T., Taylor D. et al. The prevalence and incidence of prescribing errors: systematic review: Report to The General Medical Council. December 2008. The Academy for the Study and Development of the Pharmacy Workforce. Manchester: Manchester University, 2008.
5.
Ferner RE, Aronson JKClarification of terminology in Medication Errors. Drug Saf2006;26(11):1011-22
6.
Reason J.Human Error. Cambridge: Cambridge University Press, 1990.
7.
van der Hooft CS, Sturkenboom Mcjm, van Grootheest K. et al. Adverse drug reaction-related hospitalisations. Drug Saf2006;26(2):161-8.
8.
Varghese P., Gleason V., Sorokin R. et al. Hypoglycaemia in hospitalised patients treated with antihyperglycaemic agents. J Hosp Med2007;2:234-40.
9.
Stepka M.Rogla H., Czyzyk A.Hypoglycaemia : A major problem in the management of diabetes in the elderly . Aging Clin Exp Res1993;5:117-21.
10.
Leese GP, Wang J., Broomhall J. et al. Frequency of severe hypoglycemia requiring emergency treatment in type 1 and type 2 diabetes: a population-based study of health service resource use. Diabetes Care2003;26:1176-80.
11.
Gurwitz JH, Field TS, Harrold LR et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA2003 ;289:1107-16.
12.
Lesar LSLomaestro BM, Pohl H.Medication-prescribing errors in a teaching hospital. Arch Interm Med1997;157:1569-76.
Ferner RE, Neil HAW.Sulphonylurea and hypoglycaemia. BMJ1998;296:949-50.
15.
Girardin E. , Vial T., Pham E., Evreux JCHypoglycémies induites par les sulfamides hypoglycémiants: Recensement par les Centres Régionaux de Pharmacovigilance français de 1985 à 1990. Ann Med Interne1992 ;143(1):11-17.
16.
Schlozman SC , Hennessey JVMechanical misadministration of an oral hypoglycaemic agent. Diabetes Care1997;20(11):1796-7.
Mayer GAChlorpropamide or chlorpromazine?Can Med Assoc J1991;144:119.
19.
Singh R.How a series of errors led to recurrent hypoglycaemia. J Fam Pract2006;55:489-97.
20.
Ferner RE, Neil HAW.Sulphonylureas and hypoglycaemia. BMJ1988 ;296:949-50.
21.
Amiel SA, Dixon T., Mann R., K. Jameson.Hypoglycaemia in Type 2 diabetes. Diabet Med2008;25:245-54.
22.
Shorr RI, Ray WA, Duaghty JR, Griffin MRIndividual sulfonylureas and serious hypoglycaemia in older people . J Am Geriatr Soc1996;44:751-5.
23.
Budnitz DS, Shehab N., Kegler SR, Richards CLMedication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med2007;147:755-65.
24.
Santell JP, Hicks RW, Cousins DDMedication errors in emergency department settings: 5 year review . Rockville: The United States Pharmacopeia, June 2004. http://www.usp.org/hqi/patientSafety/resources/posters/posterEmergencyDept.html. (Accessed 11 February 2009).
25.
U.S. Pharmacopeia.Insulin errors: a common problem. USP Patient Safety CAPSLink. July 2003. Section 1: USP Medication Error Analysis. Rockville: The United States Pharmacopeia, 2003. http://www.usp.org/pdf/EN/patientSafety/capsLink2003-07-01.pdf . (Accessed 12 February 2009).
26.
Santell JP, Cousins DD, Hicks R.Top 10 drugs products involved in medication errors. Drug Topics2003;147(23):HSE23-4.
27.
Cohen MR, Smetzer JL, Touhy NR, Kilo CMHigh-Alert medications: Safeguarding against errors. In: Cohen MR (ed.). Medication Errors. 2nd edition Washington, DC: American Pharmaceutical Association, 2007;317-412.
Institute for Safe Medication Practices.Proliferation of insulin combination products increases opportunity for errors. Medication Safety Alert! 27 November 2002. Horsham: Institute for Safe Medication Practices, 2002 . http://www.ismp.org/Newsletters/acutecare/articles/20021127.asp?ptr=y . (Accessed 11 February 2009).
Ponte CDMonitoring the patient with diabetes mellitus: how to avoid medication errors . Hosp Pharm1989;24:280-9.
32.
Institute for Safe Medication Practices.ISMP's List of Error-Probe Abbreviations, Symbols, and Dose Designations. Horsham: Institute for Safe Medication Practices, 2007. www.ismp.org/Tools/errorproneabbreviations.pdf . (Accessed 11 February 2009).
33.
Paparella SPAvoiding errors with insulin therapy. J Emerg Nurs2006:42:325-8.
34.
Miles M., Sweeney S.Insulin dose interpretation errors. The Pharmaceutical Journal2001;267:191-3.
Phillips W. , Lando H.Insulin confusion: an observation . Diabetes Care2002;25:1103
37.
Bates DW, Cullen DJ, Laird N. et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA1995;274:29-34.
38.
Hellman R.Patients safety and inpatient glycaemic control: translating concepts into action. Endocr Pract2006:12(3):49-55.
39.
Gill G., MacFarlane I.Are sliding-scale insulin regimens a recipe for diabetic instability?Lancet1997;349:1555.
40.
Rozich JD, Howard RJ, Justeson JM et al. Standardisation as a mechanism to improve safety in Healthcare . Joint Comm J Qual Saf2004;30(1):5-14.
41.
Donihi AC, DiNardo MM, DeVita MA, Korytkowski MTUse of a standardised protocol to decrease medication errors and adverse events related to sliding scale insulin. Qual Saf Health Care2006;15:89-91.
Derr RL, Sivanandy MS, Bronich-Hall L., Rodriguez A.Insulin-related knowledge among health care professional in internal medicine . Diabetes Spectrum2007;20:177-85.
44.
Page MD, Stephenson C., Pope RM, Bodansky HJPrescribing and dispensing of insulin: margins for error?Diabet Med1992; 9:938-41.
45.
Institute for Safe Medication Practices.ISMP quarterly action agenda: July and September 2007. ISMP Medication Safety Alert! 4 October 2007. Horsham: Institute for Safe Medication Practices, 2007. http://www.ismp.org/Newsletters/acutecare/articles/A4Q07Action.asp . (Accessed 11 July 2009).
46.
Institute for Safe Medication Practices.ISMP Medication Safety Alert!Community/Ambulatory Care Edition2007;6(9):1.
47.
Hellman R.A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract2004;10(2):100-08.
48.
Clarke NR, Narendran P.Insulin prescribing is unsafe: education results in a significant but insufficient improvement. Diabet Med2005 ; 22:1779-80.
49.
Langford NJ , Martin U., Kendall MJ, Ferner REMedical errors. Medical schools can teach safe drug prescribing and administration. BMJ2001;322:1424.
50.
Maxwell S., Walley T.Teaching safe and effective prescribing in UK medcial schools: a core curriculum for tomorrow's doctors. B J Clin Pharm2003 ;55:496-503.
51.
The ACE/ADA Task Force on Inpatient Diabetes.The American College of Endocrinology and American Diabetes Association Consensus Statement on Inpatient Diabetes and Glycaemic Control: A call to action. Diabetes Care2006;29:1955-1962.
National Patient Safety Agency.Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. December 2007. Alert Reference: NICE/NPSA/2007/PSG001 . London: National Patient Safety Agency, 2007.