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Clear, Written Instructions Can Help Avert Medical Mistakes

Aug 31, 2015

I have a patient that I introduced to using Lantus insulin (including why, injection technique, storage, etc.). She was then going to see her family doctor to actually get the prescription and return the next week so we could review titration and any new questions before she started. I saw her a week later at our supervised diabetes walking group. She reported that she had started using the insulin 3 days prior and had started at 10 units and stated she was now at 20 units! (She had only had 2 doses).

When reviewing what she thought the titration was, rather than my written instructions, she read what was written on the label prescribed by her physician. She thought it was to increase by 10 units/night! Fortunately, she was at the walking group that day and she wanted to tell me her sugars had improved! We had a chance to review the instructions and prescription and ensure she safely titrated her insulin without any hypoglycemia. Near miss for sure.


Lessons Learned:

  • To ensure patient understands starting dose and titrations doses are different, give clear written instructions to patient.
  • Be clear and tell patient that the label on the medication (bottle of insulin) may not match the instructions.
  • Ask patient to verbalize his or her understanding of how to take and titrate the dosage of insulin. Continue to discuss until you, the health care provider, feels comfortable with your patient’s response.
  • Contact patient after starting insulin to make sure the patient is taking it correctly.

Registered Nurse, Diabetes Educator