Diabetes Disaster Averted #14: Small Type Is a Big Danger
An elderly patient had attained good control with 70/30 insulin pen for a while but recently noticed his control was diminishing...
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and stopped by our diabetes education program to ask for help. He showed me his current pen. It was NPH only, from the same manufacturer. The patient had been getting samples from his equally elderly doctor, and neither noticed that he had the wrong medication. The pens looked the same, and the label used relatively small type, too small for their vision.
As soon as he received the correct medication, his control returned to its previous success.
Lesson Learned:
Have your patients bring their medications with each visit for review, making sure they understand what each medication is for and how to use it properly. This also underscores the utility of looking at the actual medicine containers. - SF
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.
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