A VA Pharmacist received an order for 40 units of U-500 insulin and questioned its validity. The actual dose desired by the physician was...
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200 units. The physician indicated the 40 units reflected the mark on a U 100 syringe to which the patient was to draw back the plunger.
This was found to be a common practice so the VA developed a system requirement which required physicians to indicate the total units/mls (Example: 200units/.4ml) for U 500. Insulin must be in the chart and syringes calibrated in mls must be used.
Keith Trettin, R. Ph., MBA (For more insight into the VA's Safety and Error Prevention procedures, see our recent Special Edition, NCPS: Taking Aim at Medication Errors.)
Bottom Line:
It would also be a good idea to indicate the dose with the words "unit markings" as this clears up the question of how much insulin to put in the syringe. - DJ
Report Medication Errors to ISMP:
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