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Disasters Averted

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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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NOTE: 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. This e-mail address is being protected from spambots. You need JavaScript enabled to view it 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.

Prescription Errors

NovoLog Mix 70/30 Confusion

When prescribing NovoLog® Mix 70/30 analog insulin, health care professionals may write an unclear prescription, or if using an EMR system, inadvertently select Novolin® 70/30 human insulin instead. Be on the lookout...


Dosing Error Due to Accent Misinterpretation

When reviewing the medical record of a hospital patient prior to meeting with her for a diabetes consult, I noted that the doctor had ordered 46 units of Lantus to be given daily at bedtime. When I went in to visit with the patient, she had a very...


Improving Patient Safety and Reducing Medical Errors in Diabetes Care

Steve Freed, Publisher, Diabetes In Control Errors in diabetes care are a common cause of complications and can result in disability and even death. The diabetes errors being reported are...


High-alert Medications Lists

From the Institute for Safe Medication Practices (ISMP): High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error. Although mistakes may or may not be more common with these drugs,...


ISMP: Similar Names But Different Actions: Potential Premix Insulin Prescription Errors

From the Institute for Safe Medication Practices (ISMP: Recently there have been reports of a mix up of mixed insulins.   The insulins involved were: NovoLog® Mix (analog) 70/30 (70% insulin...


ISMP: Why Are Insulin Medications So Prone to Error?

From The Institute For Safe Medication Practices: Insulin accounts for more than 10% of all drug mistakes. This...


A Review of Insulin Errors

This week we have a review adapted from information provided by Novo Nordisk of the most common insulin errors which include: Clinician errors Self-administration errors Self-monitoring errors ...


ISMP: Eli Lilly Working to Decrease Humulin R U-500 Errors

From the Institute for Safe Medication Practices (ISMP): Insulin errors are number #1 on the list of drugs with the most errors. A major cause for that is the use of U500 insulin. Because of that, Eli Lilly is developing a new way to inject...


Pharmacists Making a Difference

Fewer Errors in Hospitals When Pharmacists Are Involved Researchers reported last week at the conference of American Society of Health-System Pharmacists that, when pharmacists lead the...


Fulfillment Errors

NovoLog Mix 70/30 Confusion

When prescribing NovoLog® Mix 70/30 analog insulin, health care professionals may write an unclear prescription, or if using an EMR system, inadvertently select Novolin® 70/30 human insulin instead. Be on the lookout...


Improving Patient Safety and Reducing Medical Errors in Diabetes Care

Steve Freed, Publisher, Diabetes In Control Errors in diabetes care are a common cause of complications and can result in disability and even death. The diabetes errors being reported are...


High-alert Medications Lists

From the Institute for Safe Medication Practices (ISMP): High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error. Although mistakes may or may not be more common with these drugs,...


ISMP: Similar Names But Different Actions: Potential Premix Insulin Prescription Errors

From the Institute for Safe Medication Practices (ISMP: Recently there have been reports of a mix up of mixed insulins.   The insulins involved were: NovoLog® Mix (analog) 70/30 (70% insulin...


ISMP: Why Are Insulin Medications So Prone to Error?

From The Institute For Safe Medication Practices: Insulin accounts for more than 10% of all drug mistakes. This...


A Review of Insulin Errors

This week we have a review adapted from information provided by Novo Nordisk of the most common insulin errors which include: Clinician errors Self-administration errors Self-monitoring errors ...


ISMP: Eli Lilly Working to Decrease Humulin R U-500 Errors

From the Institute for Safe Medication Practices (ISMP): Insulin errors are number #1 on the list of drugs with the most errors. A major cause for that is the use of U500 insulin. Because of that, Eli Lilly is developing a new way to inject...


Pharmacists Making a Difference

Fewer Errors in Hospitals When Pharmacists Are Involved Researchers reported last week at the conference of American Society of Health-System Pharmacists that, when pharmacists lead the...


Patient Errors

"Do Not Crush, Chew or Cut"

From the Institute for Safe Medication Practices (ISMP): When a patient is prescribed a timed release medication such...


Diabetes and Tattoos: Case Study and Guidance

A 29-year-old woman with insulin-dependent diabetes noted a painful erosion at the site of the tattoo which she had gotten 7 days before. A culture isolated staphylococcus aureus confirming the clinical impression of staph. This...


A Review of Insulin Errors

This week we have a review adapted from information provided by Novo Nordisk of the most common insulin errors which include: Clinician errors Self-administration errors Self-monitoring errors ...


Basal/Bolus or is it Bolus/Basal or just Bolus/Bolus?

I had a new patient who has had diabetes for decades. She was referred to me after her blood sugars went from good to bad. I asked her to bring her supplies with her when she came in to the office for her appointment. She did so and during her...


Variety of Brands and Mixes of Insulin Medications Can Be Confusing to Patients

A patient came to my office to learn to use long-acting insulin. The referring provider's note stated that the new patient, who was establishing care without outside records, was taking only mealtime insulin: NovoLog. During my assessment, the...


It May Not Be as Simple as the Directions Say

A woman with type 2 diabetes was taking Lantus using a vial and syringe, and Novolog using a prefilled insulin pen device. Novolog was a new medication for her, and she had only been on it for 10 days. Her pre-meal glucose readings were still high...


Video Call Reveals Cause of Elevated BG

I had a type 2 patient on metformin whose blood sugars were elevated every day at lunchtime. All of his other readings including fasting, pre- and post- dinner, and bedtime, were fine. When he demonstrated his testing method over a Skype internet...


Sliding Scale or Carb Counting

Recently I saw a type 1 diabetes mellitus patient who was diagnosed in 1980 at 15 years of age. She had not seen an educator in quite some time but had changed from NPH/Regular to Lantus & Regular. She was interested in learning more about...


Wound Care - Wait for the Other Shoe to Drop

At our podiatry clinic, we had a Native American patient who came in once a week for diabetic ulcer debridement and dressing changes. He would do his home care and then return for further debridement and a new topical if the current one wasn't...


Ask the Right Questions

I do a lot of inpatient diabetes education. One of my patients was new to insulin and needed to go home on twice daily injections of 70/30. We educated her with all she needed to know to be successful at home. Two weeks after discharge the patient...


Prime and Push

This problem seems to be the one that we see most often in our office. We had a patient who had been through our diabetes education classes and came to see me for a one to one visit. She came into my office complaining that her blood sugars were...


Treatment Errors

Test Insulin Techniques of New Caregivers

The patient is a 91-year-old female with a 10-year history of type 2 diabetes. Two years ago, despite use of multiple oral hypoglycemic agents, her glycated hemoglobin (HbA1c) remained at 9.2% (77 mmol/mol) and her home glucose levels were in the...


Glucagon Label Contributes to Confusion

From our partners at the Institute for Safe Medication Practices (ISMP.org): A nurse gave orange juice to a patient with a blood glucose level of less than 50 mg/dL, but it did not raise the glucose level much, so he administered a dose of...


NovoLog Mix 70/30 Confusion

When prescribing NovoLog® Mix 70/30 analog insulin, health care professionals may write an unclear prescription, or if using an EMR system, inadvertently select Novolin® 70/30 human insulin instead. Be on the lookout...


Hemoglobin Abnormalities and A1c Testing

I recently saw a patient for a diabetes follow-up and had just gotten her lab values faxed over. Her A1c came back at 9.6 despite the patient telling me that her glucose meter readings were much lower. She even showed me...


Dosing Error Due to Accent Misinterpretation

When reviewing the medical record of a hospital patient prior to meeting with her for a diabetes consult, I noted that the doctor had ordered 46 units of Lantus to be given daily at bedtime. When I went in to visit with the patient, she had a very...


Improving Patient Safety and Reducing Medical Errors in Diabetes Care

Steve Freed, Publisher, Diabetes In Control Errors in diabetes care are a common cause of complications and can result in disability and even death. The diabetes errors being reported are...


High-alert Medications Lists

From the Institute for Safe Medication Practices (ISMP): High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error. Although mistakes may or may not be more common with these drugs,...


ISMP: Similar Names But Different Actions: Potential Premix Insulin Prescription Errors

From the Institute for Safe Medication Practices (ISMP: Recently there have been reports of a mix up of mixed insulins.   The insulins involved were: NovoLog® Mix (analog) 70/30 (70% insulin...


ISMP: Why Are Insulin Medications So Prone to Error?

From The Institute For Safe Medication Practices: Insulin accounts for more than 10% of all drug mistakes. This...


A Review of Insulin Errors

This week we have a review adapted from information provided by Novo Nordisk of the most common insulin errors which include: Clinician errors Self-administration errors Self-monitoring errors ...


ISMP: Eli Lilly Working to Decrease Humulin R U-500 Errors

From the Institute for Safe Medication Practices (ISMP): Insulin errors are number #1 on the list of drugs with the most errors. A major cause for that is the use of U500 insulin. Because of that, Eli Lilly is developing a new way to inject...


ISMP: 4,200 Need Testing after Pen Misuse

From the Institute for Safe Medication Practices: Once again, a US hospital must contend with the fact that thousands of the hospital's patients may have received an insulin injection from an insulin pen previously used for another...


Medication Safety Alert: Medtronic MiniMed Revel Insulin Pump

From our partners at the Institute for Safe Medication Practices (ISMP): Office staff at an endocrinology practice was asked to see a patient who was having low blood glucose while receiving their insulin using a Medtronic MiniMed Revel...


Basal Insulins Incorrectly Withheld

You may be surprised to learn that nurses sometimes inappropriately hold basal insulin doses (daily or every 12 hours) when a patient's blood glucose is normal at the time a dose is due. This may be appropriate for mealtime or short-acting insulin...


It's Never Too Much

When sitagliptin (Januvia) first came out, I was called by our legal affairs department about a patient of another MD at the University of Penn whose house staff had ordered 1000 mg sitagliptin instead of 100mg. As the drug had just come out, the...


Pharmacists Making a Difference

Fewer Errors in Hospitals When Pharmacists Are Involved Researchers reported last week at the conference of American Society of Health-System Pharmacists that, when pharmacists lead the...


Additional Disasters Averted

New FlexTouch Pens Not the Same as the Old

I was reviewing a client's insulin administration. She was administering Levemir (insulin detemir), 60 units, with a FlexPen. She said that she just dialed the dose to the maximum it would allow her as she knew it only would dial to 60...


IDF Diabetes Atlas - North America and Caribbean


IDF Diabetes Atlas - Africa


IDF Diabetes Atlas - Europe

Diabetes is a huge and growing...


IDF Diabetes Atlas - Southeast Asia

Diabetes is a huge and growing...


IDF Diabetes Atlas - Middle East and North Africa

Diabetes is a...


IDF Diabetes Atlas - Western Pacific

Diabetes is a huge and growing...


IDF Diabetes Atlas - South and Central America

Diabetes is a huge...


All Insulins Not the Same

I recently had a home care patient who had been discharged from a skilled nursing facility with a prescription for regular insulin, and who was put on a sliding scale dosage. The patient was experiencing hypoglycemic reactions. I was called to...


Patient's Method of Figuring Meal-time Insulin Doesn't Quite Work

Recently I assessed an 84 year old inpatient with diabetes for his insulin usage at home. In reporting his dosing he stated that after he checked his glucose before each meal he took the "first two numbers of the...


Is It Sugar-Free or Isn’t It?

One of my long term patients called my office because she could not figure out what was happening with her post breakfast glucose readings. She counted carbs and would typically have a 2 hour ppg of no more than 145 mg/dl but even though her...


Friend's Advice Causes Patient Problems

Last week I saw a patient who seemed to be losing control of her blood glucose levels. She had been doing well and her A1c had been around 6.0 - 6.3 for the past couple of years. She was doing this while only on metformin 1000 twice a day. She was...


Patient's Careful Documentation Saves Her Time and Money in the ER

One of my patients had a serious head injury from a fall which resulted in an unconscious period of time when on vacation. She spent five days in a hospital neuro unit during recovery. She had a list of all her medications, medical history...


The Obvious May Not Be that Obvious

Sometimes being a medical professional can have a major impact on the people around us outside of work. Recently, my neighbor's 12 year old daughter had a "drastic change" in her health. I noticed that she had lost a lot of weight,...



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201 Total articles for Disasters Averted


Browse our other news categories below.
A. Lee Dellon, MD | Aaron I. Vinik, MD, PhD, FCP, MACP | Beverly Price | Charles W Martin, DD | Derek Lowe, PhD | Dr. Brian Jakes, Jr. | Dr. Fred Pescatore | Dr. Tom Burke, Ph.D | Eric S. Freedland | Evan D. Rosen | Ginger Kanzer-Lewis | Greg Milliger | Kristina Sandstedt | Laura Plunkett | Leonard Lipson, M.A. | Louis H. Philipson | Maria Emanuel Ryan, DDS, PhD | Marilyn Porter, RD, CDE | Melissa Diane Smith | Michael R. Cohen, RPh, MS, ScD, FASHP | Paul Chous, M.A., OD | Philip A. Wood PhD | R. Keith Campbell, Professor, B.Pharm, MBA, CDE | Richard K. Bernstein, MD | Sheri R. Colberg PhD | Sherri Shafer | Stanley Schwartz, MD, FACP, FACE | Steve Pohlit | Steven V. Edelman, M.D. | Timothy S. Hollingshead |

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