![]() In the fatal event, the practitioner expected a numeric blood sugar value to appear on the results screen, so the numeric portion of the alarm code, W-510 ( Figure 1), was presumed to be the patient’s blood glucose value. 10,11 Insulin was incorrectly administered to both patients, one of whom died. 9 Two other events occurring within 3 months of each other involved the abbreviation RR LO, which was also misinterpreted as a high blood glucose reading. One error occurred when CR LO was misinterpreted as a high blood glucose reading, and insulin was incorrectly administered to the patient. In the events reported to FDA, practitioners misinterpreted the results on the glucometers when the blood glucose was displayed using an out-of-range abbreviation, such as RR LO (out of reportable range low limit) or CR LO (out of critical range low limit), and/or when numeric alarm codes (e.g., W-510) were displayed in a pop-up message. These events involved mistakes in interpreting patients’ blood glucose levels due to the way the results were displayed on some glucometer screens, including ACCU-CHEK Inform (no longer available from the manufacturer) and ACCU-CHEK Inform II (Roche Diagnostics), a commonly used POC glucometer by the VHA. The study was conducted in response to multiple adverse events reported to the US Food and Drug Administration (FDA) since 2010. In a more recent study conducted by the Veterans Health Administration (VHA), 8 a different type of error was described. 3 Other factors that can affect POC glucose test results include hematocrit, ascorbic acid levels, 4 and other sugars such as maltose, 5 including maltose-containing medications or parenteral solutions. 3 In the latter case, a study in a neonatal unit showed that staff failed to confirm two patient identifiers for 45% of the POC tests performed. For example, earlier studies have found that the most common types of errors associated with POC glucose testing are related to delays in testing due to the unavailability of trained staff 2 and a failure to positively identify patients prior to testing. 1 While POC glucose testing offers immediate results that can be used to make important clinical decisions about the treatment of hypo- or hyperglycemia, errors can occur at any point in the testing process. Question: The comment code DISINFECTED is used after patient testing to document the meter was cleaned between patients.Problem: Glucose testing is one of the most frequent point-of-care (POC) tests performed in hospitals. Question: Liquid quality control solutions must be performedī) Whenever a new vial of test strips is openedĬ) If you ever suspect your meter is not working properly Question: It is important to place the ACCU-CHEK in the docking station becauseĪ) The meter will pick up new admission ADT information (patient demographics)ī) The meter will load results to be utilized in Glucommander application ![]() Question: Hand hygiene and glove use is not required for whole blood glucose testing or meter cleaning. Question: Cleaning the Accu-Chek Inform II meter after each patient use:Ī) prevents transmitting contamination from one patient to anotherĬ) is a College of American Pathologists (CAP) standardĭ) must be performed using hospital approved wipes. Question: Positive patient identification is obtained by scanning the patients’ bar-coded armband. Question: When I use the ‘DO NOT CHART’ comment code I must perform a repeat within: Question: Lab verification or repeat Accu-Chek is required if the Accu-chek results are in question, result is a first time critical or result does not match the patients clinical picture. Question: Downloading the meter in the docking station (base) will perform:ī) sending patient results to Connect through the Accu-chek systemĬ) uploading of new operators, patient ADT and other pertinent information
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