To the Editor In a JAMA Performance Improvement article reporting a patient with severe hyperkalemia, Dr Hewitt and colleagues1 described the misinterpretation of an insulin order leading to a severe overdose. Although the authors discussed many factors contributing to the error and possible opportunities for improvement, they did not comment on the possible role of inconsistent packaging and methods for administration of insulin.
Rushakoff RJ, Macmaster HW. Improving Emergency Insulin Administration. JAMA. 2018;319(18):1937. doi:10.1001/jama.2018.2106
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