Inpatient medical errors involving glucose-lowering medications and their impact on patients: review of 2,598 incidents from a voluntary electronic error-reporting database
Abstract
Objective To describe characteristics of inpatient medical errors involving hypoglycemic medications and their impact on patient care. Methods We conducted a cross-sectional analysis of medical errors and associated adverse events voluntarily reported by hospital employees and staff in 21 nonprofit, nonfederal health-care organizations in the United States that implemented a Web-based electronic error-reporting system (e-ERS) between August 1, 2000, and December 31, 2005. Persons reporting the errors determined the level of impact on patient care. Results The median duration of e-ERS use was 3.1 years, and 2,598 inpatient error reports involved insulin or orally administered hypoglycemic agents. Nursing staff provided 59% of the reports; physicians reported Conclusion An e-ERS provides an accessible venue for reporting and tracking inpatient medical errors involving glucose-lowering medications. Results are limited by potential underreporting of events, particularly by physicians, and variations in the reporter perception of patient harm.
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Errors in insulin dosing, missed doses, and/or administration errors including incorrect insulin type and/or timing of dose occur relatively frequently and include prescriber, pharmacy, and nursing errors.
“Errors in insulin dosing, missed doses, and/or administration errors including incorrect insulin type and/or timing of dose occur relatively frequently (102-104) and include prescriber (ordering), pharmacy (dispensing), and nursing (administration) errors.”
From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [103]
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“The true frequency of such errors is unknown because the available data sources depend on voluntary reporting of errors (102,137) and mechanisms for real-time root-cause analysis are not available in most hospitals.”
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“The true frequency of such errors is unknown because the available data sources depend on voluntary reporting of errors (102,137) and mechanisms for real-time root-cause analysis are not available in most hospitals.”
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Result16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026
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- Authors
- Amori, R. E., Pittas, A. G., Siegel, R. D., Kumar, S., Chen, J. S., Karnam, S., Golden, S. H., & Salem, D. N.
- Affiliations
- Tufts Medical Center (US)
- Johns Hopkins University (US)
- Corresponding author
- Amori, Renee E.
- Venue
- Endocrine Practice
- Publisher
- Elsevier BV
- Published
- 2008-07
- Volume
- 14
- Issue
- 5
- Pages
- 535-542
- ISSN
- 1530-891X (ISSN-L)
- OpenAlex
- W2090870205
- Cited by
- 40
- References
- 0
- Citations by year
- 2025: 5 · 2024: 1 · 2023: 3 · 2022: 3 · 2021: 2 · 2020: 3 · 2019: 1 · 2017: 5 · 2016: 4 · 2015: 1 · 2014: 3 · 2013: 2 · 2012: 2
- FWCI
- 2.63
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Endocrine Practice (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Toxicology › Pharmacovigilance and Adverse Drug Reactions
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- medical errors, inpatient care, glucose-lowering medications, insulin, oral antidiabetic drugs, sulfonylureas, adverse events, patient harm, nurses, underreporting, hospital safety
- MeSH terms
- Cross-Sectional Studies, Humans, Hypoglycemic Agents, Insulin, Sulfonylurea Compounds, United States, Incidence, Adverse Drug Reaction Reporting Systems, Medical Errors, Drug-Related Side Effects and Adverse Reactions
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