Diabetes Disaster Averted #57: Phone Orders Prone to Errors
An elderly patient was admitted from an ECF to a Medical Subspecialty floor. She was on Lantus 8 units every night at the ECF. The nurse called the MD for admission orders. He inquired how much insulin the patient was on at the ECF. The Medicine reconciliation sheet from the ECF showed, "Glargine U 100 insulin 8 units QHS"....
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The nurse repeated to the MD, Glargine 100 units. The patient did receive this dose at bedtime and subsequently had hypoglycemia but recovered without incident.
Lesson Learned:
Often this is how insulin is written on pharmacy labels, medicine administration records and medical reconciliation sheets. Everyone must be careful when reading an insulin order and should repeat all orders taken over the phone and question doses that are unusual.
Yvonne E. Ramey, RN, CDE
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