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Diabetes Disaster Averted #64: Long-Time Insulin Users Still Make Errors

I recently met with a patient to confirm his understanding of a correction schedule based on his pre-meal blood glucose. He’d been on insulin for more than 12 years.  On the 70/30 correction schedule, he and his wife were both able to find the right doses based on the BG values I gave them for morning and evening blood glucose levels….

I then said, “I’m sure you’ll think I’m silly for asking you to show me how to draw up the dose since you’ve been on insulin for so long but….” However, instead of drawing the dose to the top of the plunger he was only pulling the dose down to the bottom of the plunger which was 8 units less than the correct dose would have been.  Both he and his wife said they had NEVER been taught how to draw up the insulin and nobody had ever asked them to show how they were drawing it up.

Needless to say, his need for increased insulin was not as much as the provider thought as he’d been taking 8 units less than what had been prescribed.

Lesson Learned:

Never assume that a long-time insulin-using patient knows the correct way to dose and inject.

Molly-Jayne Bangert, BSN RN 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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