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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 standardized protocol or order form to order insulin, including the type of coverage (e.g., low, high). Adding to the complexity of these orders are the multiple values often used for multiple ranges of blood sugars. Problems have also occurred when shortcuts are taken when writing these types of orders for insulin. For example, orders have been written stating doses of insulin as “6+1” or “6+2” instead of writing out “7” or “8” (see Figure 1).

DCMS136DA1

Once these complex orders have been written, problems have occurred when transcribing the orders to medication administration records (MARs) or entering them into computerized order-entry systems. Errors also have occurred when selecting the blood glucose range, dose, or algorithm from a pharmacy label, a handwritten MAR, or a computer-generated MAR (see Figure 2). Pennsylvania facilities are experiencing these types of errors as evidenced by these events reported to the Authority:

A patient was ordered insulin on sliding scale level 2, but the order was transcribed incorrectly on the MAR as sliding scale level 1. The patient received two doses at level 1 coverage instead of level 2. The error was found during the 24-hour MAR check.

A patient was changed from high-dose sliding scale coverage to moderate dose. Order was transcribed onto medication sheet as bedtime coverage, but original order was for no bedtime coverage. Patient received four units of insulin.

DCMS136DA2

References:

Institute for Safe Medication Practices. Proliferation of insulin combination products increases opportunity for errors. ISMP Med Saf Alert 2002 Nov 27;7(24):2.

Institute for Safe Medication Practices. Complexity of insulin therapy has risen sharply in the past decade—part I. ISMP Med Saf Alert 2002 April 17;7(8):1.

Institute for Safe Medication Practices. Safety Brief. ISMP Med Saf Alert 2000 May 3;5(9):1.

Institute for Safe Medication Practices. Getting the right insulin is becoming a real crapshoot. ISMP Med Saf Alert 2004 Jul 15;9(14):2. Complexity of insulin therapy. PA PSRS Patient Saf Advis [online] 2005 Jun [cited 2009 Nov 11]. Available from Internet: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2005/jun2(2)/Documents/30.pdf

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Diabetes in Control would like to acknowledge the Institute for Safe Medication Practices’ outstanding work in medication safety, including the above excerpt.

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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