A patient who felt he was good at multi-tasking gave himself the wrong insulin. Instead of taking 10 units of long acting insulin, he gave himself 10 units of rapid acting insulin....
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Luckily he realized the mistake and took steps to correct the situation successfully.
Lesson Learned:
For your patients on multiple types of insulin, make sure they understand how each type of insulin is used and the onset, peak and duration of each one. Let them know what to do in case of a mix-up, and also how to prevent this from happening by using items to color code vials and/or keep them on different shelves.
This is a very common mistake that can be very dangerous but is entirely preventable. In the U.S. the number one error in medications comes from the use of insulin.
Gabrielle C. Skelton, Nutritionist
To prevent this error, check out our Product of the Week from Issue #563: Securitee Blankets for your vials of Insulin.
With insulin costing up to 100 dollars a vial, the Securitee Blanket at five dollars is great insurance that can prevent the vial from breaking if dropped. But even more importantly it can help prevent patients who use different insulins from picking up and using the wrong medication.
Available at Amazon for $4.99 in multiple colors and sizes:
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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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.
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