INPATIENT MEDICAL ERRORS INVOLVING GLUCOSE-LOWERING MEDICATIONS AND THEIR IMPACT ON PATIENTS: REVIEW OF 2,598 INCIDENTS FROM A VOLUNTARY ELECTRONIC ERROR-REPORTING DATABASE

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 <2%. Approximately two-thirds of the errors (1,693 of 2,598) reached the patient. Errors that caused temporary harm necessitating major treatment or that caused permanent harm accounted for 1.5% of reports (40 of 2,598). Insulin was involved in 82% of reports, and orally administered hypoglycemic agents were involved in 18% of all reports (473 of 2,598). Sulfonylureas were implicated in 51.8% of reports involving oral hypoglycemic agents (9.4% of all reports). Conclusion: An e-ERS provides an accessible venue for reporting and tracking inpatient medical errors involv ing glucose-lowering medications. Results are limited by potential underreporting of events, particularly by physi cians, and variations in the reporter perception of patient harm.(EndocrPract.2008;14:535-542)