From our partners at the Institute for Safe Medication Practices (ISMP): Most pharmacy-generated labels, both in acute care and outpatient settings, display the name and strength (i.e., concentration) of the drug on the same line.
For Humalog, many labels read “Humalog 100 units/mL” on the first line with the intended dose for the patient appearing on the line below the drug name and concentration (see Figures 4 and 5). Similarly, pharmacy-provided, computer-generated MARs and other forms of drug information display dosage strength or concentration information the same way as the label. Display of drug and dosing information in this way has led practitioners to misinterpret the drug’s strength or concentration (100 units/mL) as the patient’s dose. Although this issue was only apparent in 14 events reported, it is of great concern because of the potentially large difference between the intended dose and the administered dose.
- Patient was on Lantus insulin at the nursing home. When physician was reviewing the medication orders from the nursing home, the Lantus order read “Lantus 100 units/ml vial inject 15 units sub q at bedtime.” The physician misinterpreted this order to mean Lantus 100 units sub q at bedtime and ordered it as such. The patient’s blood sugar was 85 [that evening], so this dose was not given, and it was subsequently decreased to 80 units. The patient did receive the 80 units the next day, and the blood sugar dropped to 52 two days later. The Lantus dose was decreased again to 40 units on the following day and was administered at bedtime. [The follow morning,] the patient arrested, and patient’s blood sugar was 12.
- The printed medication list from a previous facility indicated “Lantus 100 units/ml 15 units once a day subcutaneously at 8pm.” The nurse reconciling the patient’s medications misread the order as 100 units. The medications were reviewed with the physician and obtained telephone order for “Lantus 100 units SQ at hs.” The nurse administering medications gave as ordered. The patient’s medication reconciliation form indicates that the patient takes 100 units of Lantus in addition to Januvia® and metformin. When I saw these medications ordered for [the evening dose], I questioned the patient on the amount of Lantus he takes at home. He said “15 cc.” I explained that insulin comes in units. I brought him a syringe and asked how high he fills it, and he pointed to 15 units. I asked how much he had last night, and he said the nurse brought in a large syringe full of insulin. The nurse gave 100 units of Lantus last night according to the computer screen. The patient only takes 14 units at dinnertime.
Diabetes in Control would like to acknowledge the Institute for Safe Medication Practices’ outstanding work in medication safety, including the above excerpt.
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