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Clear, Written Instructions Can Help Avert Medical Mistakes

Jan 5, 2021

Why written medical instructions are necessary.

I have a patient I introduced to using Lantus insulin (including why, injection technique, storage, etc.). She would then see her family doctor, get the prescription and return the next week to 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 three days prior and started at ten units and stated she was now 20 units! (She had only had two 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 ten 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 safely titrate her insulin without hypoglycemia. Near miss, for sure. 

Lessons Learned: 

  • To ensure the patient understands the starting dose and titrations doses are different, give clear written instructions. 
  • Be clear and tell the patient that the label on the medication (bottle of insulin) may not match the instructions. 
  • Ask the patient to verbalize their 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 




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See more cases of how simple steps like written instructions can help prevent medical issues in our Disasters Averted center.