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Free but Costly

Aug 12, 2012
A patient in our comprehensive diabetes education program had received a meter set in mmoles/L from a durable medical equipment company.

She wasn’t sure why or how she had received the free monitor and strips, but chose to use them anyway. Her physician had suggested she initiate insulin therapy almost two months previous. With the meter set in the mmoles/L, however, she thought she was doing well and did not need insulin.

She was disregarding the decimal point in the belief that a value of 10.0 was 100 when in actuality it was 180mg/dl.

Fortunately, our educator took on the role of detective, asking this patient to demonstrate her meter use, and questioning her about her recorded BG log entries. If the educator had not asked these important questions, the patient’s high BG would not have been discovered until the A1C test results had come back.

Once she realized what her true BG levels were, she immediately started on basal insulin.

Providers do not always view patient logs, they make treatment changes based on A1C levels. So if the provider had convinced the patient to start insulin and her test results went even lower using the mmoles/L reference method, the patient could have then been treated for hypoglycemia when in fact she was not. This would have caused the patient angst and even possible weight gain from unnecessary treatment.

Lesson Learned:
  1. Asking the patient to demonstrate how they use their diabetes devices is important. Don’t just look at logs.
  2. Warn patients that different countries may use a different unit of measurement. (We have many Canadian winter residents in our area so this is especially important for us.)
  3. Review patient logs or preferably download meters to see if test results correlate with A1C levels.
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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Copyright © 2012 Diabetes In Control, Inc.

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