An underweight 77-year-old white male with 20-year history of insulin-dependent DMT2 was admitted to community hospital’s emergency department with fever, chills, irregular heartbeat, and infrequent foamy urine output. Alert but disoriented to time and place….
During morning multidisciplinary rounds, a pharmacy ICU rotation student mentioned to his preceptor the lack of tight glycemic control, and the missing urine glucose value. He also questioned the appropriateness of Vanco as treatment for UTI. Clinical pharmacist consulted with duty nurse and dietician. A new UA test was ordered, and chart recommendations for change in antibiotic treatment were made in the patient chart. No med order changes made for several hours.
Urinalysis results returned that afternoon showed many Gram-negative rods, nitrite test positive, with a (very) positive result for glucose in urine. Med orders changed at 4:55 pm to:
- Start Bactrim DS, BID; continue Cipro 500 BID
- Start Levemir insulin qHS, continue Novolin sliding scale
- D/C dextrose 50% in water
- D/C IV vancomycin
- Start normal saline, 1 liter stat plus 500 mL/hour thereafter
- Monitor urine output; torsemide for dieresis delivered "on call"
- Other changes not relevant to his diabetes and urine glucose
Patient condition improved throughout the 2nd night and he was transferred non-ICU private room on the 3rd day. When asked why more insulin was not given and why urine output volumes were not noted on the first night, nurse responded that "patient was not eating or drinking, therefore did not require insulin."
This case highlights one of the common risks of hospital stays for diabetic patients: the discontinuation of their normal insulin regimen and the initiation of a reactive sliding-scale "one-size-fits-all" strategy to glycemic control. Without a full accounting of this patient’s medical history, the risks of severe infection and acute renal failure became unnecessarily real and urgent. The time lags inherent to sliding-scale therapy nearly resulted in disaster in this case.
Eric Nielsen, Saint Petersburg FL
UF College of Pharmacy Ambulatory Care rotation student
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
Next Diabetes Disaster Averted →