Friday , August 17 2018
Home / Resources / Disasters Averted / Diabetes Disaster Averted #14: Small Type Is a Big Danger

Diabetes Disaster Averted #14: Small Type Is a Big Danger

Dec 13, 2010

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.

Lesson Learned:

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:

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.



And if you have a “Diabetes Disaster Averted” story, please also send it in separately to Diabetes In Control. If we use it you will receive a Visa Gift Card worth $50.00. Click here to let us know the details. (You can use your name or remain anonymous if you prefer.) Please note that ISMP is not associated with this Gift Card promotion.

Copyright © 2011 Diabetes In Control, Inc.


←Previous Diabetes Disaster Averted 
Managing Weight-Loss Insulin Changes

Next Diabetes Disaster Averted 
Handling Accidental Insulin Injection

For the complete list of Diabetes Disasters Averted, just follow this link.