Inpatient medical errors involving glucose-lowering medications and their impact on patients: review of 2,598 incidents from a voluntary electronic error-reporting database

Endocr Pract. Jul-Aug 2008;14(5):535-42. doi: 10.4158/EP.14.5.535.


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 involving glucose-lowering medications. Results are limited by potential underreporting of events, particularly by physicians, and variations in the reporter perception of patient harm.

MeSH terms

  • Adverse Drug Reaction Reporting Systems / statistics & numerical data*
  • Cross-Sectional Studies
  • Drug-Related Side Effects and Adverse Reactions / epidemiology
  • Drug-Related Side Effects and Adverse Reactions / etiology
  • Humans
  • Hypoglycemic Agents / adverse effects*
  • Incidence
  • Insulin / adverse effects
  • Medical Errors / statistics & numerical data*
  • Sulfonylurea Compounds / adverse effects
  • United States / epidemiology


  • Hypoglycemic Agents
  • Insulin
  • Sulfonylurea Compounds