An elderly patient had attained good control with 70/30 insulin pen for a while, but recently noticed his control was diminishing…
and stopped by our diabetes education program to ask for help. He showed me his current pen. It was NPH only, from the same manufacturer. The patient had been getting samples from his equally elderly doctor, and neither noticed that he had the wrong medication. The pens looked the same, and the label used relatively small type, too small for their vision.
As soon as he received the correct medication, his control returned to its previous success.
Have your patients bring their medications with each visit for review, making sure they understand what each medication is for and how to use it properly. This also underscores the utility of looking at the actual medicine containers. – SF
Report Medication Errors to ISMP:
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