# Therapeutic errors involving diabetes medications reported to United States poison centers

## TL;DR

This study examines diabetes medication errors reported to US poison centers from 2000 to 2021, finding a significant rise in errors and some serious outcomes.

## Contribution

The study provides a comprehensive analysis of trends and outcomes of diabetes medication errors reported to poison centers over two decades.

## Key findings

- There was a 279.8% increase in diabetes medication errors from 2000 to 2011.
- 9.9% of cases had serious medical outcomes, including 17 fatalities, with metformin accounting for 59% of deaths.
- Insulin and sulfonylureas were associated with the highest rates of serious outcomes and hospital admissions.

## Abstract

To investigate the characteristics and trends of therapeutic errors that occur outside of healthcare facilities involving diabetes medications reported to US poison centers.

National Poison Data System data from 2000 to 2021 were retrospectively analyzed.

There were 157,623 exposure cases of non-healthcare facility-related therapeutic errors associated with diabetes medications as the primary substance reported to US poison centers from 2000 to 2021. The rate of all therapeutic errors involving diabetes medications increased by 279.8% from 2000 to 2011, followed by a slower 15.0% increase to 2021. Half (50.1%) of the exposure cases were treated/evaluated and released and 44.1% did not receive treatment in a healthcare facility; however, 9.9% experienced a serious medical outcome, including 17 fatalities, and 1.0% were admitted to a critical care unit and 2.2% to a non-critical care unit. Insulin had the highest rates of therapeutic errors and serious medical outcomes, while sulfonylureas and insulin had the highest medical hospital admission rates. Metformin accounted for 59% (n = 10) of fatalities.

Although most cases of therapeutic errors involving diabetes medications had no or minimal clinical consequences, an important minority were associated with a serious medical outcome or medical hospital admission. Increased efforts to prevent therapeutic errors involving diabetes medications are warranted.

The online version contains supplementary material available at 10.1186/s40621-024-00536-y.