The mistake was caught 2 hours later when the infant’s blood glucose measured 3 mg/dL. Rapid treatment with dextrose boluses ensued, and the blood glucose returned to normal within 12 hours.
When dealing with infants, insulin can be very dangerous due to its concentration and has to be diluted. To prevent errors, formulas and dilution procedures need to be reviewed before using and everything needs to be documented.
R. Shah, MD
Report Medication Errors to ISMP:
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