This type of “Disaster Averted” has been sent to us a number of times and can be prevented by ensuring that your patients are correctly educated and prepared to avoid such events.
Our diabetes team has been working with a type 2 diabetes patient who has been on insulin for more than 10 years, and is on basal bolus treatment plan. One evening before bedtime she took her usual dose of 20 units of long acting insulin. After about 15 minutes she begin to feel the effects of hypoglycemia. She then went back to where she keeps her insulin supplies for glucose tablets to treat the hypoglycemia. At that point she noticed that she had taken 20 units of her rapid acting insulin in error instead of her long acting insulin. Because she caught her mistake in time she was able to prevent a potentially serious hypoglycemic reaction and a trip to the emergency room.
Insulin vials and many insulin pens look and even feel the same. Teach your patients to take a piece of tape or mark the bottles and/or pens with a colored marker or any other method so that when they are tired or in a hurry, they will not make the mistake of picking up and using the wrong insulin. A person who is on basal bolus insulin treatment will inject 2-8 times daily. Over a period of 10 years (as in this patient’s example) they would inject themselves about 20 to 30,000 times and could easily pick up the wrong insulin when tired or in a rush.
Marvin Chase, MD
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.
And if you have a “Diabetes Disaster Averted” story, please also send it in separately to Diabetes In Control. If we use it you will receive a Visa Gift Card worth $50.00. Click here to let us know the details. (You can use your name or remain anonymous if you prefer.) Please note that ISMP is not associated with this Gift Card promotion.
Copyright © 2012 Diabetes In Control, Inc.
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