Diabetes Disaster Averted #4: Patient Query Helps to Catch Dosing Error

on a mixed insulin (75/25 ) 25 units before breakfast and 15 units before dinner. On reviewing her chart I saw where the doctor had changed her insulin to Novolog before each meal, dose based on her blood sugars, and Lantus 30 units at bedtime. I then checked her medication log and realized that she was still receiving her 75/25 insulin in addition to her new insulin orders. When I looked at the physician order sheet, I noticed that the physician had not discontinued her 75/25 insulin. I spoke to the patient's nurse and told her to immediately stop the 75/25 insulin and call the doctor to discontinue the older insulin order. I also reviewed the nurse on different insulin regimens and actions.

Fortunately, the patient only received two doses of the 75/25 insulin after the new insulin orders went into effect and her blood sugars went back to normal a few hours later. It is important for patients in a hospital setting to question staff if it appears that they are receiving more doses of their insulin than they are used to getting at home.

(Submitted anonymously)

Bottom Line:

Often times patients get new medications from their prescribers with no clear cut orders to discontinue the older medication. This happens both in and out of the hospital. It is a good idea to ask patients what they are taking rather than just assuming the chart is correct and they are only getting medications from you. -- DJ