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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...


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...


Patient Errors

Exercise Not Guaranteed to Lower Blood Glucose

John, a gentleman in his 70's who has diabetes, always visited my group after he exercised. I noticed he always had something (hard candy) in his mouth and he seemed tired. I asked him why he was doing this candy thing. He said, "After exercise...


Treat the Whole Patient, Not Just Part

We were running a clinical study on erectile dysfunction. An obese 68-year-old male came in looking for help for his ED, so he thought he might qualify for the study. He had not had a medical workup for some time and wasn't aware of any underlying...


Hypoglycemia Can Impact Job Performance

A 55-year-old woman with type 2 diabetes who was being treated with glimiperide had had a difficult time finding a job. She was finally hired into a law firm as a legal secretary. She would be frequently called into meetings at the last minute,...


Using Pens - Keep It In and Hold It Down!

Susan received a phone call from her clinician's office recommending that she start using a pen for her insulin. She had also been prescribed a GLP-1 receptor agonist and was to go to the pharmacy to pick them up. She went and signed up for...


Dealing with Difficult Patients

Ricardo, a 35-year-old man newly diagnosed with type 1 diabetes, was hospitalized for diabetic ketoacidosis (DKA). Once he was stabilized, he wanted to go home. He refused to learn how to self-administer insulin. However, he was told he would not...


Not All Insulin Pens are the Same

Recently, a patient of mine called about her post-meal glucose levels which were increasing. She had not made any changes to food choices, there were no health changes, and so my first thought was that her insulin was bad. I had the patient get a...


Assessing Insulin Administration Technique

An 83-year-old woman who lived alone and was very active in her community was having wide swings in her glucose levels. She reported sometimes waking up hours after dinner with her head in her dinner plate. She did not understand why. She...


Remote Wireless Monitoring Can Help Patients Newly Diagnosed with T1

A patient of mine was newly diagnosed with type 1 diabetes. He started on insulin and I taught him about


What's Hiding in that Insulin Box?

Last week in the pharmacy we received an electronic refill authorization for regular and nph insulin. The patient had been using the two insulins together for about two years and seemed to be in relatively good control. The refills had the sig code...


"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 ...


Treatment Errors

Hypoglycemia Can Impact Job Performance

A 55-year-old woman with type 2 diabetes who was being treated with glimiperide had had a difficult time finding a job. She was finally hired into a law firm as a legal secretary. She would be frequently called into meetings at the last minute,...


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...


Additional Disasters Averted

Helping Your Patients Choose Alternate Testing Sites Wisely

About one and a half years ago I was evaluating the educational needs of a mid-30's, female, hospital in-patient with diabetes mellitus type 2 (DM2). She and her husband both had DM2. Both were slender, active, did carb counting and followed all...


Diabetes Misinformation Can Delay Treatment, Advance Complications

Can we "prevent" diabetes with weight loss? Or would it be better to say we can "delay" diabetes with healthy behavior? Often people are reluctant to admit that they have diabetes or to initiate treatment. Many times...


Change Language to Combat Feelings of Failure

A patient presented for outpatient diabetes education stating, "I really don't know why I am here. I know I need to lose weight. I don't know what else you can tell me." She was reassured when I told her that there are people who are a...


CGM Best Fit for Active Type 1 Patients

Janelle, an RN, is 36 years old with type 1 diabetes. She has a busy life between family and work. She eats healthy, exercises regularly, and wears a pump but occasionally has severe hypoglycemia, especially during exercise and at...


Custom Molded Shoes: If the Shoe Doesn't Fit...

A patient of mine who had diabetes and peripheral neuropathy came home from the hospital after a below-the-knee amputation of her right leg. She lived alone and was housebound. Having lost one leg, I knew she was at increased risk for losing her...


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...



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215 Total articles for Disasters Averted


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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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