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Diabetes Disaster Averted #49: Indication Can Prevent Errors

For a patient with known diabetes, a pharmacy technician typed the medication order in Figure 1 as “Lantus inject 80 units at bedtime,” then dispensed 3 vials or 30 mL. The pharmacist read the order the same way while checking the technician’s work but said to herself, “This doctor doesn’t know how to spell Lantus”….

That made her check a little further. When she accessed the patient’s drug profile she saw that the patient was already on LEVEMIR (insulin detemir [rDNA origin] injection) along with LATUDA (lurasidone) 40 mg, an atypical antipsychotic drug. The dose was being increased to 80 mg.

Serious harm could have occurred had the pharmacist not been suspicious enough to check further. The incident serves as a reminder about the importance of communicating the drug’s purpose on the prescription, especially when prescribing recently marketed drugs. Latuda gained FDA approval in October 2010.

Lesson Learned: Include purpose on Rx. If the prescription had stated the purpose to prevent psychosis the error would never occur.

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Figure 1 — Latuda prescription was mistaken as Lantus.

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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