Recently, I met with a patient on Byetta 5mcg with a prescription for 10mcg as her continuation dose by a physician in the practice I work in.
Advertisement
She had been given a sample pen of Byetta 5 mcg and instructed on the use of the pen by the physician's medical assistant. The patient called in requesting a refill prescription of the Byetta 10mcg in about two weeks. The MA of the physician who had started the patient on the drug called in the refill. About two weeks later the patient called in again for another refill, reporting that she was nauseous, not eating much but losing weight which she was happy about. This time I received the request for refill because the physician was not available. After reviewing the patient's chart and Byetta refill history I gave the patient a call to find out why she needed the refills so often when one pen should last up to a month.
She reported that she was taking the injections as she was instructed to do. I then asked her to describe to me how she dialed the dose and where she was injecting. She said she dialed to "5 clicks" on the pen and then injected 5 times! I immediately asked the patient to come see me so we could review the injection procedure. She came in that afternoon. With the use of a teaching aid she demonstrated her understanding of how to use the pen. She dialed the dose 10mcg correctly and injected into the teaching aid but without removing the needle she again dialed another 10mg four times pushing on the plunger each time. She said that when she was initially trained on how to use the pen she was told to take "5mcg" which she interpreted to mean five injections.
I reviewed the correct procedure and then observed her using the corrected technique. We discussed the action, dose, side effect, injection site rotation and adverse reaction to the drug and I gave the patient written instructions.
Lesson Learned:
Patients should both verbally repeat and then physically demonstrate their understanding of our instructions.
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.
*****
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.
DISCLAIMER: The content of this Website is independent of the views of our advertisers and sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.
Copyright @ 1999-2013 Diabetes In Control, Inc.. All rights reserved.
