Patient Safety Topics

In events involving insulin reported to the Pennsylvania Patient Safety Authority, more than half led to situations in which a patient may have or actually received the wrong dose or no dose of insulin, which could lead to difficulties in glycemic control. Strategies to address these problems include limiting the variety of insulin products, developing standardized protocols and a standardized prescription format, avoiding the use of abbreviations, and requiring an independent double check of all doses before dispensing and administering intravenous insulin.

Key Data and Statistics

​Pennsylvania healthcare facilities submitted 2,685 event reports to the Authority from January 2008 to June 6, 2009, that mentioned medication errors involving the use of insulin products.

The predominant medication error event types associated with insulin (see Table) were drug omission (24.7%) followed by wrong drug (13.9%) and wrong dose/overdosage (13%).

Table. Predominant Medication Error Event Types Associated with the Use of Insulin (N = 2,057, 76.6%), January 2008 to June 6, 2009 ​ ​
Event TypeNumber% of Total Reports (N = 2,685)*
Dose omission66224.7%
Wrong drug37413.9%
Wrong dose/overdosage34813%
Other (specify)30911.5%
Extra dose2278.5%
Wrong dose/underdosage1375.1%
* Sum of percentages exceeds 76.6% due to rounding.


Educational Tools

Organization Assessment of Safe Insulin Practices
This tool will aid facilities in assessing the safety of insulin practices and identify opportunities for improvement. Facilities can use the findings to develop an action plan for implementing recommended error reduction strategies.

Insulin Measures Worksheet
This sample worksheet may be used for documenting facility-specific process and outcome measures involving the use of insulin.

Treating Hyperkalemia—Avoid Additional Harm When Using Insulin and Dextrose
Safety Tips for Patients