The 1999 publication of the Institute of Medicine’s (IOM’s) review of medical errors, To Err is Human: Building a Safer Health System (1), along with the publication of Michael Cohen’s book, Medical Errors (2), highlighted the impact that medical errors have on the U.S. health care system and the potential for high morbidity and possible fatal outcome for the individual patient (7,000+ deaths per year from medication errors). Throughout the country, health care providers, hospitals, and delivery systems are making elimination of medication-related errors a top priority, with strong support from major employers and the federal government. A cultural shift must occur, moving from “blame the individual,” to an approach looking for the root cause of errors and focusing on system-wide changes to prevent recurrence. Until universal availability of physician order-entry, bar-coding, and other innovative methods to reduce errors are a reality (acknowledging that nothing is foolproof), errors will continue to plague our dysfunctional health care system.
By looking at the stages of the medication process, physicians’ orders have been identified as the most common source of preventable errors. Insulin has been singled-out repeatedly as one of the medications most frequently involved in medication errors. Both the IOM’s 1999 report and Cohen’s book identify insulin as the medication with the greatest likelihood for harm when errors occur. Hand-written orders for insulin using the letter “U” for “units” leads to errors with 10-fold or more increases in insulin dosages occurring as the letter “U” is mistaken for a 0, 4, or 6. By establishing a task force to address this error in our hospital and making insulin order sheets with the word “units” preprinted in the order area, we have significantly reduced insulin-related errors.
The American Diabetes Association (ADA) is in the unique position to greatly reinforce the use of “units” for writing insulin orders throughout the U.S. and world health care systems. Eliminating the use of “U” in ADA publications and adopting an aggressive stance on this will make a tremendous impact on the health of diabetic patients by protecting them from insulin overdosage. Please incorporate these changes and help lead the world in the elimination of medical errors.
References
Address correspondence to Daniel J. Crowe, Medical Director, Diabetes Resource Center, Portsmouth Regional Hospital, 333 Borthwick Ave., Suite 104, Portsmouth, NH 03802. E-mail: [email protected].
Note from the Editor: When Dr. Crowe brought this problem to the attention of the ADA professional publications staff in May of this year, they immediately began spelling out “units” in text and revising figures whenever possible. The change has been in effect since the August issues of Diabetes and Diabetes Care and the summer issues of Diabetes Spectrum and Clinical Diabetes. Although the use of “units” may take a little longer to become apparent in ADA’s books and pamphlets, ADA staff have made a commitment to promoting this practice.
