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.
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.
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There has been much written about problems with handwritten orders for insulin, including the use of dangerous abbreviations or dose expressions and other shortcuts when communicating orders. How the use of the letter "U" to abbreviate...
Clarity in Insulin Coverage Orders, Part 2
From our partners at the Institute for Safe Medication Practices (ISMP): One problem often seen with coverage orders is the clarity of handwritten orders from physicians, a particular problem when an organization does not have a...
Clarity in Insulin Coverage Orders
From our partners at the Institute for Safe Medication Practices (ISMP): The Diabetes Control and Complications Trial, a prospective, randomized controlled trial of intensive versus standard glycemic control involving inpatients with...
Wrong-Drug Errors Associated with Insulin Products
This week's Disaster Averted comes courtesy of ISMP.
There are numerous case reports in the literature that discuss the issue of wrong-drug medication errors with insulin products due to similarities in the...
ISMP: A Clinical Reminder about the Safe Use of Insulin Vials
This feature article by our partner in diabetes safety, the Institute for Safe Medication Practices, summarizes the risks of insulin pen use in hospitals, the crucial importance of proper training for a safe transition to the use of insulin vials...
Multiple Safety Checks Missed Resulting in Double-dose Error
Several months ago I saw a patient with a 15-year history of type 2 diabetes. He was seeing both a primary care provider and an endocrinologist. On reviewing his medications I realized that he was taking Glucophage XR 750 tid and metformin...
Two Prescriptions But Only One Medication
Last week we had a patient new to our practice come into our office with a bag full of all her medications.
Educating Patients to Counter Prescription Fulfillment Errors
Recently a patient came to our diabetes center for education and to improve her control. Her physician had given her a new prescription for insulin. Since the patient had never had any formal diabetes education she wanted to wait until after her...
Changing Medications
At a recent support group meeting, a patient raised his hand and told me that he had been prescribed both Lantus and Levemir, and was taking them both at night.
Same Brand, Different Pens
Recently, a patient with an inexplicably high A1c was referred to me.
From our partners at the Institute for Safe Medication Practices (ISMP): The Diabetes Control and Complications Trial, a prospective, randomized controlled trial of intensive versus standard glycemic control involving inpatients with...
Wrong-Drug Errors Associated with Insulin Products
This week's Disaster Averted comes courtesy of ISMP.
There are numerous case reports in the literature that discuss the issue of wrong-drug medication errors with insulin products due to similarities in the...
Determining Medical History in an Emergency
I work in an emergency room and more than once we have had patients with diabetes come in with either severe hypoglycemia, or hyperglycemia and DKA. It is very difficult at times for us to decide on treatment because we don't always have the...
ISMP: A Clinical Reminder about the Safe Use of Insulin Vials
This feature article by our partner in diabetes safety, the Institute for Safe Medication Practices, summarizes the risks of insulin pen use in hospitals, the crucial importance of proper training for a safe transition to the use of insulin vials...
Multiple Safety Checks Missed Resulting in Double-dose Error
Several months ago I saw a patient with a 15-year history of type 2 diabetes. He was seeing both a primary care provider and an endocrinologist. On reviewing his medications I realized that he was taking Glucophage XR 750 tid and metformin...
Two Prescriptions But Only One Medication
Last week we had a patient new to our practice come into our office with a bag full of all her medications.
Educating Patients to Counter Prescription Fulfillment Errors
Recently a patient came to our diabetes center for education and to improve her control. Her physician had given her a new prescription for insulin. Since the patient had never had any formal diabetes education she wanted to wait until after her...
Same Brand, Different Pens
Recently, a patient with an inexplicably high A1c was referred to me.
Wrong-Drug Errors Associated with Insulin Products
This week's Disaster Averted comes courtesy of ISMP.
There are numerous case reports in the literature that discuss the issue of wrong-drug medication errors with insulin products due to similarities in the...
Patients (and Caregivers) Must Demonstrate Insulin Injection Technique
A patient came into our emergency room recently with severe hypoglycemia (blood glucose of 34 mg/dl).
Accidents Will Happen But Damage Can Be Minimized
Over the years I have had many patients come into the pharmacy requesting a replacement bottle of insulin because they've accidentally dropped a bottle. Recently, a patient shared this experience:
Determining Medical History in an Emergency
I work in an emergency room and more than once we have had patients with diabetes come in with either severe hypoglycemia, or hyperglycemia and DKA. It is very difficult at times for us to decide on treatment because we don't always have the...
Insulin Pump Trainers and Training
An insulin pump trainer who worked with a pump company recently trained one of our patients in his home.
Diabetic Complications and Frostbite
Diabetes, and more specifically, diabetic complications such as neuropathy and poor circulation, made headline news last week when the 68-year old British explorer, Sir Ranulph Fiennes, had to pull out of a grueling expedition to cross...
Changing Doses Can Be Confusing
A woman with newly diagnosed type 2 diabetes mellitus and also on blood pressure and anti-lipid medication was given prescriptions for: glucophage 500mg QD for one week, and then an increase to two 500mg tablets the second week.
Patient's Attempt to Increase Potency of Medication
Last week we had a patient come in to the pharmacy with a prescription for sildenafil 100 mg to be used as directed.
Grams versus Grams
As a diabetes educator and insulin pump trainer I request that my patients keep several days of food records prior to assessment visits.
Different Insulins Should Be Clearly Marked
This type of "Disaster Averted" has been sent to us a number of times and can be prevented by ensuring that your patients are correctly educated and prepared to avoid such events.
Transcription Error Caught Just in Time
Often as medical professionals we are around people that we could make a difference with and we are hesitant to do anything for fear of offering unsolicited advice, or liability issues.
The Most Common Error Made when Using an Insulin Pen
This type of error has been sent to us at least 60 times. So as a medical professional you should be aware of this issue when showing a patient how to use an insulin pen.
Multiple Safety Checks Missed Resulting in Double-dose Error
Several months ago I saw a patient with a 15-year history of type 2 diabetes. He was seeing both a primary care provider and an endocrinologist. On reviewing his medications I realized that he was taking Glucophage XR 750 tid and metformin...
Maintaining and Monitoring Good Habits
After working with patients for 25 years I have learned that they can do the same thing right for a long time and then suddenly do something entirely different.
Longtime Insulin Users Can Still Make Mistakes
Recently I saw a type 1 diabetes mellitus patient who had been diagnosed in 1980 at 15 years old.
Insulin Pump Safety Measure
I was working with a patient who'd recently had a pump upgrade and although he said he didn't have any issues with infusion set changes, I urged him to change his set while I was present.
A Fundamental, Pervasive Insulin Error Source
I recently met with a patient and his wife to confirm their understanding of a correction schedule based on his pre-meal blood glucose.
Insulin Pen Delivery Failures
I just encountered the second patient in the past six months new to using pens who was "taking" the insulin with the inner needle shield left on.
Insulin Timing and Hypoglycemia
Recently, I saw a patient who was a seasoned insulin user.
Insulin and Extremes in Temperature
Last summer, we were traveling in the Southwest and stopped for a meal in a local diner. As a diabetes educator my ears always perk up when I hear someone talk about insulin so when I overheard the waitress talking to a customer about her...
Alternate Site Testing While Driving
One of my clients had an A1C of 7.5% but her blood sugars were all over the chart.
Educating Elderly Patients
Several years ago, I had a 70-year-old patient who was starting on an insulin pump.
Drug Induced Hypoglycemia, Police Assault and Incarceration Disaster
Complications go beyond co-morbidities for blind diabetes patient...
At our VA hospital, I had been treating a 62-year-old legally blind veteran patient for diabetes. At first, he had not...
Changing Medications
At a recent support group meeting, a patient raised his hand and told me that he had been prescribed both Lantus and Levemir, and was taking them both at night.
Why Patient Demo's Are Important
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.
Dialing in the Wrong Number
When you turn the dose selector to dial a dose of insulin using a Novo Flexpen, the number of units to be administered appears in a dose window.
Patient's Medication Re-organization Solves Problem
A clinic patient called to complain about hypoglycemia, fatigue, dizziness and a weight gain of 5 pounds in the last two weeks. The patient was on 500 mg Metformin bid and had purposely lost 40lb over the last six months with diet and...
Free but Costly
A patient in our comprehensive diabetes education program had received a meter set in mmoles/L from a durable medical equipment company.
There has been much written about problems with handwritten orders for insulin, including the use of dangerous abbreviations or dose expressions and other shortcuts when communicating orders. How the use of the letter "U" to abbreviate...
Clarity in Insulin Coverage Orders, Part 2
From our partners at the Institute for Safe Medication Practices (ISMP): One problem often seen with coverage orders is the clarity of handwritten orders from physicians, a particular problem when an organization does not have a...
Clarity in Insulin Coverage Orders
From our partners at the Institute for Safe Medication Practices (ISMP): The Diabetes Control and Complications Trial, a prospective, randomized controlled trial of intensive versus standard glycemic control involving inpatients with...
ISMP: IV Insulin Administration
From our partners at the Institute for Safe Medication Practices (ISMP), this week we have a review of IV Insulin Administration and two examples of what can go wrong when the correct procedures are not adhered to.
Wrong-Drug Errors Associated with Insulin Products
This week's Disaster Averted comes courtesy of ISMP.
There are numerous case reports in the literature that discuss the issue of wrong-drug medication errors with insulin products due to similarities in the...
Diluting Insulin for Infants
A 3-day-old infant weighing 1.3 kg was prescribed total parenteral nutrition containing 1 unit of regular insulin per each 327-mL bag.
ISMP: Updating Your High-Alert Medication List
Because insulin is at the top of the "High-Alert Medication List," we are presenting this updated article from our partner at ISMP (Institute for Safe Medication Practices).
Insulin Pump Trainers and Training
An insulin pump trainer who worked with a pump company recently trained one of our patients in his home.
ISMP: A Clinical Reminder about the Safe Use of Insulin Vials
This feature article by our partner in diabetes safety, the Institute for Safe Medication Practices, summarizes the risks of insulin pen use in hospitals, the crucial importance of proper training for a safe transition to the use of insulin vials...
The Most Common Error Made when Using an Insulin Pen
This type of error has been sent to us at least 60 times. So as a medical professional you should be aware of this issue when showing a patient how to use an insulin pen.
Multiple Safety Checks Missed Resulting in Double-dose Error
Several months ago I saw a patient with a 15-year history of type 2 diabetes. He was seeing both a primary care provider and an endocrinologist. On reviewing his medications I realized that he was taking Glucophage XR 750 tid and metformin...
Gastric Reflux Symptons Can Be Misread
John, 59 years old, was diagnosed with type 1 diabetes at two years of age.
Two Prescriptions But Only One Medication
Last week we had a patient new to our practice come into our office with a bag full of all her medications.
Inspecting Injection Areas
I had a patient recently who asked me to look at his abdomen as he said it was red and tender. He had been using this area for a number of years. His blood sugars were not well controlled as evidenced by an A1c of 9%....
A Fundamental, Pervasive Insulin Error Source
I recently met with a patient and his wife to confirm their understanding of a correction schedule based on his pre-meal blood glucose.
Insulin Pen Delivery Failures
I just encountered the second patient in the past six months new to using pens who was "taking" the insulin with the inner needle shield left on.
Navigate through our listing of Disasters Averted articles here.
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