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This article originally posted and appeared in  Safety and Error PreventionDiabetes Clinical Mastery Series Issue 45Treatment Errors

Diabetes Disaster Averted #45: Pharmacist Follow-up Catches Insulin Oversight

An underweight 77-year-old white male with 20-year history of insulin-dependent DMT2 was admitted to community hospital's emergency department with fever, chills, irregular heartbeat, and infrequent foamy urine output. Alert but disoriented to time and place….

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Patient was stabilized and transferred to Intensive Care Unit with med orders for IV Dextrose 50% in water, IV Vancomycin, P.O. Cipro 500, and (hospital standard) sliding-scale insulin regimen. Preliminary diagnosis: urinary tract infection. Urinalysis performed, glucose was not noted. SS Novolin instructions begin 121-150 mg/dL, give 0 units; 151-200 mg/dL, give 1 unit, etc. Throughout the night, point-of-care blood glucose readings of 137, 149, 188, and 197 were noted. Total of 2 units insulin delivered. Urine output continued to be infrequent and discolored. 

During morning multidisciplinary rounds, a pharmacy ICU rotation student mentioned to his preceptor the lack of tight glycemic control, and the missing urine glucose value. He also questioned the appropriateness of Vanco as treatment for UTI. Clinical pharmacist consulted with duty nurse and dietician. A new UA test was ordered, and chart recommendations for change in antibiotic treatment were made in the patient chart. No med order changes made for several hours. 

Urinalysis results returned that afternoon showed many Gram-negative rods, nitrite test positive, with a (very) positive result for glucose in urine. Med orders changed at 4:55 pm to:

  • Start Bactrim DS, BID; continue Cipro 500 BID
  • Start Levemir insulin qHS, continue Novolin sliding scale
  • D/C dextrose 50% in water
  • D/C IV vancomycin
  • Start normal saline, 1 liter stat plus 500 mL/hour thereafter
  • Monitor urine output; torsemide for dieresis delivered "on call"
  • Other changes not relevant to his diabetes and urine glucose

Patient condition improved throughout the 2nd night and he was transferred non-ICU private room on the 3rd day. When asked why more insulin was not given and why urine output volumes were not noted on the first night, nurse responded that "patient was not eating or drinking, therefore did not require insulin."

Lesson Learned:

This case highlights one of the common risks of hospital stays for diabetic patients: the discontinuation of their normal insulin regimen and the initiation of a reactive sliding-scale "one-size-fits-all" strategy to glycemic control. Without a full accounting of this patient's medical history, the risks of severe infection and acute renal failure became unnecessarily real and urgent. The time lags inherent to sliding-scale therapy nearly resulted in disaster in this case.

Eric Nielsen, Saint Petersburg FL

UF College of Pharmacy Ambulatory Care rotation student

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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Copyright © 2011 Diabetes In Control, Inc.

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This article originally posted 08 August, 2011 and appeared in  Safety and Error PreventionDiabetes Clinical Mastery Series Issue 45Treatment Errors

Past five issues: Diabetes Clinical Mastery Series Issue 212 | GLP-1 Special Editions October 2014 | Issue 752 | SGLT-2 Inhibitors Special Edition October 2014 | Diabetes Clinical Mastery Series Issue 211 |


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