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Diabetes Disaster Averted #9: Calibrating Correctly

Nov 13, 2010

A VA Pharmacist received an order for 40 units of U-500 insulin and questioned its validity. The actual dose desired by the physician was…

200 units. The physician indicated the 40 units reflected the mark on a U 100 syringe to which the patient was to draw back the plunger.

This was found to be a common practice so the VA developed a system requirement which required physicians to indicate the total units/mls (Example: 200units/.4ml) for U 500. Insulin must be in the chart and syringes calibrated in mls must be used.

Keith Trettin, R. Ph., MBA (For more insight into the VA’s Safety and Error Prevention procedures, see our recent Special Edition, NCPS: Taking Aim at Medication Errors.)

Bottom Line:

It would also be a good idea to indicate the dose with the words “unit markings” as this clears up the question of how much insulin to put in the syringe. – DJ

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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