Thursday , December 14 2017
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Checking Everything Twice

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

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