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Dialing in the Wrong Number

When you turn the dose selector to dial a dose of insulin using a Novo Flexpen, the number of units to be administered appears in a dose window.

In Figure 1, the dose that has been dialed is 46 units. But we recently received an interesting report from an RN/Certified Diabetic Educator (CDE) about a patient who suffered an overdose by misreading the amount actually dialed. The patient arrived at a hospital emergency department unconscious with a blood sugar of 20 mg/dL. She was treated and later questioned in order to understand how she was administering her medication.

She demonstrated how she dialed the dose by reading the numbers to the right of the dosing window, not within it. In other words, she actually was giving 46 units when she thought she was giving herself 6 units! This is the first and only report we’ve had like this but thought we’d make readers aware so they can double-check that patients are reading the dose in the right location. Incidentally, the nurse educator cited other problems we hadn’t heard about either, such as patients inserting the needle but not pushing the push button to release the insulin injection, or instead of pushing the push button they turn the dial, expecting that will lead to injection. All the more reason to have patients meet with a CDE before self-administering an insulin pen.

DCMS99-DA-Fig1

Figure 1. Patient using a Flexpen gave herself 46 units of Novolog, not the 6 units she was prescribed.

Lesson Learned:

Patients should always meet with a CDE or other trained medical professional before self-administering an insulin pen and, in that first meeting, should demonstrate their technique on themselves before filling the prescription and administering at home.

Courtesy ISMP 2012

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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