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Educating Patients to Counter Prescription Fulfillment Errors

Recently a patient came to our diabetes center for education and to improve her control.

Her physician had given her a new prescription for insulin. Since the patient had never had any formal diabetes education she wanted to wait until after her classes to see if she could control her blood glucose with an improved meal plan instead of the insulin. Current A1c was 8.7%. We contacted the physician who agreed to this arrangement. Since insulin was a possibility, though, I taught the patient about insulin and how to use a vial and syringe, as well as a pen.

Several months went by and the patient returned for a review of insulin pen use as she needed to start insulin. I noticed immediately that the instructions were in cc’s, not units! I called the physician’s office to confirm the order and they faxed the original notes. We then called the pharmacy and had the pharmacist read back the prescription, and he said because he couldn’t understand the physician’s writing, he made an assumption, and filled the prescription. He insisted the prescription read cc’s so that is what he wrote. When the pharmacy faxed us a copy of the prescription, we were able to decipher the prescription and it was, in fact, for 10u S/C QD. When I questioned the dispensing of insulin in cc’s instead of units the response was “that was the order.”

This prescription was dispensed as 10cc once daily. If this patient had taken 10cc’s instead of 10 units, it could have been a fatal error.

Lessons Learned:

When a patient is first given a prescription for insulin, you should also:

  1. Educate each patient on how insulin works in their body, and the dangers of hypoglycemia should be emphasized.
  2. Instruct the patient on how to use an insulin pen, as well as a syringe and vial.
  3. The medical professional should provide the patient with instructions, and the patient needs to verbalize these instructions to show that they know exactly what they need to do.

Anonymous

 

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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