One of my clients had an A1C of 7.5% but her blood sugars were all over the chart.
She had been coming for three months with these readings but no explanation for the 37 to 300 mg/dl range. She said she never felt a low and did not know why the readings were high. She tested three times a day. At one session, I asked what was going on when she had the 37 mg/dl blood sugar and she replied that she had forgotten to test before she left the house after lunch, was driving down the road and remembered. She tested and was at 37 mg/dl. I asked, “Were you having low symptoms?” and she said “No.” I then cautioned her about the low, and testing while driving. That was when she said, “I test on my arm and it is easy to drive and test.” Alternate site testing was not working for her. The next two weeks I had her test only on her fingers. The blood sugar test results became more consistent and she did not report any unusually low readings.
I now ask all clients with wide variations in blood sugars what sites they use to test, then caution them to not use alternate site testing while the blood sugar levels are unstable. We need to take the time to explain alternate site testing to all clients newly diagnosed and even review this kind of testing for those who have had diabetes a long time. Testing should be consistent and the sites should be consistent. In addition, any patient on insulin or a sulfonylurea should always test before getting behind the wheel.
Report Medication Errors to ISMP:
Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.
And if you have a “Diabetes Disaster Averted” story, please also send it in separately to Diabetes In Control. If we use it you will receive a Visa Gift Card worth $50.00. Click here to let us know the details. (You can use your name or remain anonymous if you prefer.) Please note that ISMP is not associated with this Gift Card promotion.
Copyright © 2012 Diabetes In Control, Inc.
|←Previous Diabetes Disaster Averted
Educating Patients to Counter Prescription Fulfillment Errors
Next Diabetes Disaster Averted →