From our partners at the Institute for Safe Medication Practices (ISMP.org): A nurse gave orange juice to a patient with a blood glucose level of less than 50 mg/dL, but it did not raise the glucose level much, so he administered a dose of IV GLUCAGON EMERGENCY (glucagon) per policy. When the patient’s blood glucose was checked about 30 minutes later, the glucose level was still less than 50 mg/dL. Orange juice was given again, but 20 minutes later, the patient’s glucose level remained less than 50 mg/dL. Another glucagon injection was given, which raised the blood glucose into the 50s. More oral carbohydrates were given until, finally, the patient’s blood glucose returned to normal.
Later, the nurse who administered the glucagon injections mentioned that he had administered a dose measured in units because the label on Lilly’s Glucagon Emergency Kit (Figure 1) and vial indicates the dose is “1 mg (1 unit).”…
The nurse was new and had never administered glucagon. He said he used a U-100 insulin syringe to administer the 1 unit dose each time. He did not realize that “1 unit,” in this case, meant a full mg as indicated by the marking on the syringe contained in the kit. The patient had received only 1/100 of the required dose, even though a pharmacy label on the product said, “Inject 1 mg (1 unit) subcutaneously every 15 minutes as needed if blood glucose is less than 60 mg/dL and patient unable to take glucose products by mouth.” Apparently, the nurse became confused when he saw “1 unit” and used an insulin syringe to measure each dose.
While the likelihood of a similar error occurring again is small, we did ask Lilly to look at the product labeling to consider whether the dose in units is needed.
GLUCAGON HYPOKIT (glucagon), distributed by Novo Nordisk, lists the dose only in mg (1 mg) on the primary display panel. According to Lilly’s Glucagon Emergency Kit directions, the syringe that contains the diluent is to be used to withdraw the dose (to the 1 mg mark on the syringe) and then also to inject it. The facility is also committed to improving staff training on the topic of glucagon administration.
Thanks to our partners at www.ismp.org