Human factors are important to consider in the effort to reduce errors in insulin therapy. Even a highly skilled and knowledgeable provider of care may make a serious error if their sequence of steps during clinical care is interrupted, and these errors often are not noticed when rushed. Yet, along with a propensity for cognitive errors, humans have remarkable cognitive flexibility. A successful culture of safety must include back-up checks to discover these human errors and use the cognitive flexibility of the team members to create an environment that has patient safety as the highest priority.
Finally, the best institutions will need to consider the danger of burdening the clinical team with nonclinical priorities. The more the clinical team is rewarded primarily for nonclinical priorities, the harder the task becomes for making insulin therapy safe for every patient.
References
1. “High-alert” medications and patient safety (Patient safety alert). Int J Qual Health Care 2001;13(4):339–340
2. Cousins D, Rosario C, Scarpello J. Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency. Clin Med 2011;11(1):28-30
3. Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract 2004;10(Suppl. 2):100–108
4. Cobaugh DJ, Maynard G, Cooper L, Kienle PC, Vigersky R, Childers D, Weber R, Carson SL, Mabrey ME, Roderman N, Blum F, Burkholder R, Dortch M, Grunberger G, Hays D, Henderson R, Ketz J, Lemke T, Varma SK, Cohen M. Enhancing insulin-use safety in hospitals: practical recommendations from a ASHP Foundation expert consensus panel. Am J Health-Syst Pharm 2013;70:e18–27
5. Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montor VM, Seley JJ, Van den Berghe G. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2012;97:16–38
6. Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Ismail-Beigi F, Kirkman MS, Umpierrez GE. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009;32:1119–1131
7. Healy D, Cromwell J. Hospital-acquired conditions–present on admission: examination of spillover effects and unintended consequences. Final Report. RTI International CMS Contract No: HHSM-500-2005-00029I, September 2012, Accessed Jan 2016. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/06_hospital-acquired_conditions.asp
8. Kohn LT, Corrigan JM, Donaldson MS (Eds.); Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC, National Academies Press, 2000
9. Reason J. Human Error. Cambridge, UK, Cambridge University Press, 1990
10. Hughes RG (Ed.). Nurses at the “sharp end” of patient care. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD, Agency for Healthcare Research and Quality, 2008, chap. 2
11. Hellman R. Patient safety and inpatient glycemic control: translating concepts into action. Endocr Pract 2006;12(Suppl. 3):49–55
12. Bates D, Clark NG, Cook RI, Garber JR, Hellman R, Jellinger PS, Kukora JS, Petak SM, Reason JT, Tourtelot JB. American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. Endocr Pract 2005;11(3):197–202
13. Bogner, MS. Human Error in Medicine. Hillsdale, NJ, Erlbaum, 1994
14. Korytkowski M, DiNardo M, Donihi AC, Bigi L, DeVita M. Evolution of a diabetes inpatient safety committee. Endocr Pract 2006;12(Suppl. 3):91–99
15. Maynard G, Kulaza K, Ramos P, Childers D, Clay B, Sebasky M, Fink E, Field A, Renvall M, Juang PS, Choe C, Pearson D, Serences B, Lohnes S. Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract 2014;Dec 22:1–34 [Epub ahead of print]
16. Draznin B, Gilden J, Golden S, Inzucchi SE, for the PRIDE investigators. Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes Care 2013;36:1807–1814
17. Dungan K, Lyons S, Manu K, Kulkarni M, Ebrahim K, Grantier C, Harris C, Black D, Schuster D. An individualized inpatient diabetes education and hospital transition program for poorly controlled hospitalized patients with diabetes. Endocr Pract 2014;20(12):1265–1273
18. Hellman R. An individualized inpatient diabetes education and hospital transition program for poorly controlled hospitalized patients with diabetes. Endocr Pract 2014;20(10):1097–1099
19. Pichardo-Lowden AR, Kong L, Haidet PM. Knowledge, attitudes and decision-making in hospital glycemic management: are faculty up to speed? Endocr Pract 2015;21(4):307–322. doi:10.4158/EP14246.OR
20. Hellman R, Draznin B. Do we need to broaden the scope of inpatient diabetes education to include our faculty? Endocr Pract 2015;21(4):448–449
21. Goldman E, Shah K, Greenberg L, Cogen FR. A pediatric resident diabetes curriculum targeting different learning styles. Diabetes Spectr 2012;25(1):45–48
22. Maynard G, Schnipper JL, Messler J, Ramos P, Kulasa K, Nolan A, Rogers K. Design and implementation of a web-based reporting and benchmarking center for inpatient geriatrics. J Diabetes Sci Technol 2014;8(4):630–640
23. Schuster KM, Barre K, Inzucchi SE, Udelsman R, Davis KA. Continuous glucose monitoring in the surgical intensive care unit: concordance with capillary glucose. J Trauma Acute Care Surg 2014;76(3):798–803
24. Joseph J, Torjman MC, Strasma PJ. Vascular glucose sensor symposium: continuous glucose monitoring systems (CGMS) for hospitalized and ambulatory patients at risk for hyperglycemia, hypoglycemia, and glycemic variability. J Diabetes Sci Technol 2015;9(4):725–738
25. Poljakova I, Elsikove E, Chlup R, Kalabus S, Hasala P, Zapletalova J. Glucose sensing module––is it time to integrate it into real-time perioperative monitoring? An observational pilot study with subcutaneous sensors. BiomedPap Med Fac Univ Palacky Olomouc Czech Repub 2013;157:1–12
26. Maynard G, O’Malley CW, Kirsh SR. Perioperative care of the geriatric patient with diabetes or hyperglycemia. Clin Geriatr Med 2008;24:649–665
27. Blood glucose monitoring test systems for prescription point-of-care use. Draft guidance for industry and Food and Drug Administration Staff. Washington, DC, US Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health, Office of In Vitro Diagnostic Device Evaluation and Radiological Health, Division of Chemistry and Toxicology Devices, 2014
28. Scott MG, Bruns DE, Boyd JC, Sacks DB. Tight glucose control in the intensive care unit: are glucose meters up to the task? Clin Chem 2009;55:18–20
29. Rice MJ, Pitkin AD, Coursin DB. Glucose measurement in the operating room: more complicated than it seems. Anesth Analg 2010;110:1056–1065
30. Dungan K, Chapman J, Braithwaite SS, Buse J. Glucose measurements: confounding issues in setting targets