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Disasters Averted

Table of Contents

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

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...


When Dealing with U100 Think Concentration Not Dose

Courtesy of our partners at ISMP: One of my patients was asked to write out his home medications which he then did, including "U100 Novolin R insulin before meals and bedtime." The nurse entered this into the E-chart for home meds...


Avandia, Not Coumadin -- Coumadin, Not Avandia

From our partners at ISMP (Institute for Safe Medication Practices) - Last week the US Food and Drug Administration (FDA) notified health professionals about their determination that recent data for rosiglitazone-containing drugs, such as...


Patient's "Non-compliance" Avoids Dangerous Error

Recently I visited a patient for a diabetes education consult. The patient was on glargine and lispro sliding scale insulin. As I explained about sliding scale insulin, he said that during a previous admission to the hospital, he was given a...


ISMP - From the Hospital to Long-term Care: Protecting Vulnerable Patients during Handoffs

Problem: More than 3 million Americans will rely on services provided by long-term care (LTC) facilities at some point during 2013, and more than 1.4 million will live in the nearly 16,000 LTC facilities on any given day.1 About...


U-500 Insulin

From our partners at the Institute for Safe Medication Practices (ISMP): Most insulin products are supplied from the manufacturer in a 100 unit/mL concentration. The insulin is then administered using an insulin syringe specially...


Fulfillment 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...


Avandia, Not Coumadin -- Coumadin, Not Avandia

From our partners at ISMP (Institute for Safe Medication Practices) - Last week the US Food and Drug Administration (FDA) notified health professionals about their determination that recent data for rosiglitazone-containing drugs, such as...


Patient's "Non-compliance" Avoids Dangerous Error

Recently I visited a patient for a diabetes education consult. The patient was on glargine and lispro sliding scale insulin. As I explained about sliding scale insulin, he said that during a previous admission to the hospital, he was given a...


ISMP - From the Hospital to Long-term Care: Protecting Vulnerable Patients during Handoffs

Problem: More than 3 million Americans will rely on services provided by long-term care (LTC) facilities at some point during 2013, and more than 1.4 million will live in the nearly 16,000 LTC facilities on any given day.1 About...


Safe Use of Insulin Pens

From our partners at the Institute for Safe Medication Practices (ISMP): Given reports of ongoing misuse of insulin pens -- in particular, the sharing of insulin pens with multiple patients after only changing the needle -- we believe...


U-500 Insulin

From our partners at the Institute for Safe Medication Practices (ISMP): Most insulin products are supplied from the manufacturer in a 100 unit/mL concentration. The insulin is then administered using an insulin syringe specially...


Patient 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...


Influenza Vaccine – Shake Well!

From our partners at the Institute for Safe Medication Practices - This is the season where we recommend that patients with diabetes get vaccinated for the flu virus. Patients can usually get the flu vaccine at their doctor's office,...


Sometimes Is Not the Same as Always

One of our patients returned recently to our office for a Continuous Glucose Monitor (CGM) download and a review of his food log. At an earlier visit he had experienced a hypoglycemic reaction. Just as before, the patient was in a hurry to get to...


The Power and Dangers of Advertising

Recently a 69 year old man returned to see me after being started on a single bedtime dose of Levemir via the Flex pen along with a long acting sulfonylurea. He had received education about basal insulin action from the start. On return his morning...


Too Common Insulin Pen Error

A patient who was new to insulin therapy and her husband were coached on how to use an insulin pen. The patient and her husband decided that he would give her the injections and the patient's glucose results were fine. After a few weeks, the...


Safety Needles Cause Confusion

I was asked to see a patient for instruction on insulin administration. After leaving the hospital she had started her insulin at home. During a telephone conversation she mentioned that she was concerned that after injection she noticed some...


Monitoring Homecare Patients

In my 25 years of nursing, I can recall many incidents of "Diabetes Disasters Averted." Here are just two that happened to our homecare patients.


Measuring and Drawing Insulin

I recently took care of a patient who came in with hypoglycemia: her blood glucose level was 34 mg/dl. She had been recently discharged from the hospital prior to this admission and was advised to increase her Glyburide from 5 mg to 10 mg...


Patient's "Non-compliance" Avoids Dangerous Error

Recently I visited a patient for a diabetes education consult. The patient was on glargine and lispro sliding scale insulin. As I explained about sliding scale insulin, he said that during a previous admission to the hospital, he was given a...


Family History Creates Insulin Confusion

Recently I saw a patient in his 70's, with type 2 diabetes who had been on insulin for over 6 months. Family history revealed a son with type 1. The patient had been sent for diabetes education from a clinic where he was seen for dizziness and...


Injection Sites Confused

A patient of mine with type 2 diabetes had recently started on Lantus. I asked her about her injection sites and how they were feeling. She stated that her arms were sore and she was experiencing pain while injecting. I asked her to show me her...


Medical ID Bracelet

A new patient, a young man recently diagnosed with diabetes, was aware of the problems associated with alcohol and hypoglycemia but liked to go out with friends on the weekend.  I stressed the need for a medical ID bracelet and after a...


Click It Like a Pen

A new patient who had been using insulin pens for two years came in for a consult because his blood sugars continued to go up even though his doctor kept increasing the dose of insulin. He was on a very large amount of insulin. Our endocrinologist...


Inappropriate Insulin Pump Infusion Sites

I was following-up with an insulin pump patient in the hospital. I had been told he did not have his infusion set and supplies with him, so I brought a set with me. Once I arrived at the room, however, the patient informed me that his family had...


Insulin Dose Errors with Insulin Pump Tubing

Patients with diabetes using the MiniMed Paradigm insulin pump from Medtronic should be aware of the potential for a dosing error if insulin or another fluid contacts the inside of a tubing connector, the US Food and Drug Administration (FDA)...


Preventing Insulin Errors: Risk Reduction Strategies

From our partners at the Institute for Safe Medication Practices (ISMP): Organizations should strive to identify system-based causes of errors with the use of both insulin vials and insulin pen devices and implement effective...


Treatment 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...


When Dealing with U100 Think Concentration Not Dose

Courtesy of our partners at ISMP: One of my patients was asked to write out his home medications which he then did, including "U100 Novolin R insulin before meals and bedtime." The nurse entered this into the E-chart for home meds...


Safety Needles Cause Confusion

I was asked to see a patient for instruction on insulin administration. After leaving the hospital she had started her insulin at home. During a telephone conversation she mentioned that she was concerned that after injection she noticed some...


Measuring and Drawing Insulin

I recently took care of a patient who came in with hypoglycemia: her blood glucose level was 34 mg/dl. She had been recently discharged from the hospital prior to this admission and was advised to increase her Glyburide from 5 mg to 10 mg...


Patient's "Non-compliance" Avoids Dangerous Error

Recently I visited a patient for a diabetes education consult. The patient was on glargine and lispro sliding scale insulin. As I explained about sliding scale insulin, he said that during a previous admission to the hospital, he was given a...


Using IV Insulin

From our partners at ISMP: An IV insulin bag was hung when replacing the patient's Versed® (midazolam) bag. Two bags of insulin were then hanging, one at rate of 8 (Versed rate) and one at 5 (insulin rate). A [mid-afternoon] accucheck...


ISMP - From the Hospital to Long-term Care: Protecting Vulnerable Patients during Handoffs

Problem: More than 3 million Americans will rely on services provided by long-term care (LTC) facilities at some point during 2013, and more than 1.4 million will live in the nearly 16,000 LTC facilities on any given day.1 About...


Diabetic Foot Calluses: Protective or Problematic?

Calluses protect the body because, without that layer of thickened skin, pressure or friction could cause an open wound. However, in patients with peripheral neuropathy and diabetes, calluses may be covering up a much deeper wound or ulceration....


Insulin Dose Errors with Insulin Pump Tubing

Patients with diabetes using the MiniMed Paradigm insulin pump from Medtronic should be aware of the potential for a dosing error if insulin or another fluid contacts the inside of a tubing connector, the US Food and Drug Administration (FDA)...


Safe Use of Insulin Pens

From our partners at the Institute for Safe Medication Practices (ISMP): Given reports of ongoing misuse of insulin pens -- in particular, the sharing of insulin pens with multiple patients after only changing the needle -- we believe...


Insulin Pens Used on Multiple Patients

From our partners at the Institute for Safe Medication Practices (ISMP): Safe use of insulin pens for inpatients has been called into question once again.


Preventing Insulin Errors: Risk Reduction Strategies

From our partners at the Institute for Safe Medication Practices (ISMP): Organizations should strive to identify system-based causes of errors with the use of both insulin vials and insulin pen devices and implement effective...


U-500 Insulin

From our partners at the Institute for Safe Medication Practices (ISMP): Most insulin products are supplied from the manufacturer in a 100 unit/mL concentration. The insulin is then administered using an insulin syringe specially...


Additional Disasters Averted

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,...



Navigate through our listing of Disasters Averted articles here.
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178 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. Bernstein | 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 | 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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