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Diabetes Disaster Averted #4: Patient Query Helps to Catch Dosing Error

I was working as a diabetes nurse in a hospital when a patient I was seeing asked me to find out why she experienced two recent hypoglycemic episodes. She came into the hospital…

on a mixed insulin (75/25 ) 25 units before breakfast and 15 units before dinner. On reviewing her chart I saw where the doctor had changed her insulin to Novolog before each meal, dose based on her blood sugars, and Lantus 30 units at bedtime. I then checked her medication log and realized that she was still receiving her 75/25 insulin in addition to her new insulin orders. When I looked at the physician order sheet, I noticed that the physician had not discontinued her 75/25 insulin. I spoke to the patient’s nurse and told her to immediately stop the 75/25 insulin and call the doctor to discontinue the older insulin order. I also reviewed the nurse on different insulin regimens and actions.

Fortunately, the patient only received two doses of the 75/25 insulin after the new insulin orders went into effect and her blood sugars went back to normal a few hours later. It is important for patients in a hospital setting to question staff if it appears that they are receiving more doses of their insulin than they are used to getting at home.

(Submitted anonymously)

Bottom Line:

Often times patients get new medications from their prescribers with no clear cut orders to discontinue the older medication. This happens both in and out of the hospital. It is a good idea to ask patients what they are taking rather than just assuming the chart is correct and they are only getting medications from you. — DJ

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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