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Diabetes Disaster Averted #49: Indication Can Prevent Errors

Sep 5, 2011

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.


Figure 1 — Latuda prescription was mistaken as Lantus.

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