In December, ISMP published an article re: adverse glycemic events and critical emergencies. Safe practice recommendations included steps to avoid insulin mix-ups. Historically, we have experienced these errors in our ED and worked to limit the number of insulin products available, with a goal of removing regular insulin vials from the ED and sending patient-specific doses (diluted) for IV administration. Note: we also recently moved to EPIC with some prospective order review in the ED and Pyxis profiling, but there are still some gaps in coverage to be fixed)