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Diabetes Disaster Averted #61: Double-Checking Dosages

A patient was admitted through the emergency room for a non-diabetes related event. At admission, it was reported that she took 36 units of Humalog twice daily. The primary care physician reviewed the current insulin dose, before he wrote the orders and thought it “didn’t sound quite right”….

After further investigation, it was discovered that this patient was taking Humalog 75/25 insulin twice daily.

Lesson Learned:

If this patient had been given 36 units Humalog instead of the Humalog 75/25, she would have had severe hypoglycemia. Ask patients what type of insulin they are using, and clarify if they are taking the plain analog or if it is a pre-mixed insulin.

Connie J. Buss, RD, LD, CDE

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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