Root causes of intraoperative hypoglycemia: a case series

Perioperative Hyperglycemia Management

“…Undoubtedly, care must be taken to appropriately monitor patients in the perioperative setting to prevent dangerous drops in blood sugar. Conservative BG targets, 7 frequent monitoring, perioperative provider communication, 72 and treatment algorithms that base doses on insulin sensitivity, 59 jointly reduce the risk of intra and post-operative hypoglycemia.…”

Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel

“…13,38,39 The types of errors that these recommendations aim to prevent are consistent with those reported by others. 14,16,18,23,30,31,34,40,41 Since the release of the Institute of Medicine report "To Err Is Human: Building a Safer Health System" in 1999, 42 health care providers, professional organizations, policymakers, and other stakeholders have worked to decrease medication errors in hospitals and throughout the health system. These steps traverse the medication-use process and include technology implementation (e.g., computerized prescriber order entry, bedside barcode-assisted medication administration systems, intelligent infusion devices), further integration of evidence-based guidelines in standardized order sets and clinical decision-support systems, establishment of patient safety and medication safety officer positions in hospitals, increased emphasis on the delivery of care through interdisciplinary team processes, emphasis on medication safety at transitions of care (e.g., medication reconciliation), and enhanced health professional education.…”

“…The Institute for Safe Medication Practices (ISMP) identifies insulin as an inpatient high-alert medication. 14 Insulin is frequently cited as one of the medications commonly implicated in medication errors in hospitals, [15][16][17][18][19][20][21][22][23][24][25][26][27][28] and insulin-related medication errors have the potential to result in serious harm, including death. The American Academy of Pediatrics, which has led pediatric patient safety efforts, has emphasized the importance of safe insu- The authors acknowledge Brandi Goswick, B.S., for administrative support of the expert panel meeting and consensus-building process, and the Bernard Consulting Group for facilitation of the expert panel meeting.…”

Communication related to medication incidents—A concept analysis and literature review

“…4) Contextual and process issues: Contextual and process issues are presented together for avoid repetition, because process phases occur always in some context. Contextual issues consisted of communication methods, channels, equipment used [32,28,27] and tasks of communication [1,42,24,34,10,43]. Contextual issues concerned also communication situation [43,44,24,35] and environment of communication [1,10,31,30,27].…”

“…Contextual issues consisted of communication methods, channels, equipment used [32,28,27] and tasks of communication [1,42,24,34,10,43]. Contextual issues concerned also communication situation [43,44,24,35] and environment of communication [1,10,31,30,27]. Communication methods as contextual issues consisted of verbal or nonverbal methods, including silence used face-to-face or over the phone [1, 35,45].…”