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Diabetes Disaster Averted #7: Double-Checking Calculations Saves Patient from Multiple Problems

I am a Nurse Practitioner, CDE, working in a busy endocrinology practice and seeing mainly diabetes patients. One of the endocrinologists started a patient on….

Humulin R U 500 insulin. He gave the patient written instructions with her dosage and when to start. He also asked the patient to come in to follow up with me on the day that she started the new insulin. Fortunately she had an early morning appointment and had not started taking her new insulin. As usual I always double-check the calculated dose of insulin especially U 500. After I did, the patient said that my dose was much less than what she was instructed to take: 70 units of U 500 insulin before each meal. My calculations were for the patient to take 15 units before each meal. I immediately checked with the endocrinologist who realized that he had made an error in the calculation. This could have been a very dangerous situation for patient if she had taken even one dose of this amount of insulin.

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