Tuesday , September 18 2018
Home / Conditions / Type 2 Diabetes / Checking Everything Twice

Checking Everything Twice

Jul 2, 2012
We had something happen in our office recently that I had never expected to occur.

We had finally convinced one of our type 2 patients that the once-a-day shot of Glargine was not enough to control her glucose levels and that it was now time to start on a fast-acting insulin at mealtime. She had been using a vial and syringe for her 50 units of Lantus and we decided to give her a pen for her Humalog and started her on 6 units at each meal. We had one of our MA’s get a pen from the fridge and instruct the patient on how to inject. We also sent an electronic script to her pharmacy for her to pickup after using the sample. Our on-call NP got a call the next morning at 4 am with the patient reporting a low glucose level of 41mg/dl which the patient treated with glucose tabs.
The NP was somewhat confused as to what could have caused this low and wondered if the patient had not gotten the instructions right for dosing the Humalog. She had the patient return to the office later that day to make sure she was using the pen correctly and when the patient came in we discovered what had happened.

Our MA had given the patient a pen for Humalog 75/25 rather than plain Humalog and this evidently was what had caused the overnight lows.

We gave the patient the proper pen and the problem disappeared.

Lesson Learned:

It is a good idea for the prescriber or another office person to verify that the sample is correct. In addition we are now making sure that our MA’s verify that the insulin they get from the fridge is the same that is on the electronic record.

Abby Aronson, ARNP

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.



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.

Copyright © 2012 Diabetes In Control, Inc.

←Previous Diabetes Disaster Averted 
The Importance of Explaining Medications’ Actions to Patients

Next Diabetes Disaster Averted 
Long-acting Insulin x 2

For the complete list of Diabetes Disasters Averted, just follow this link.