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This article originally posted and appeared in  Safety and Error PreventionPatient ErrorsDiabetes Clinical Mastery Series Issue 114

Longtime Insulin Users Can Still Make Mistakes

Recently I saw a type 1 diabetes mellitus patient who had been diagnosed in 1980 at 15 years old.

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She had not seen an educator in quite some time but had changed from NPH/regular insulin to Lantus and regular.  She was interested in learning more about the insulin pens that were available. As we were discussing her routine she became less responsive in her answers and started digging into her purse but did not know what she was looking for.

I decided to check her blood sugar and she was 25. We were able to avoid a catastrophic event and her blood sugar came up to 99 after 45 grams of carbs 45 minutes later.

In further discussion, I learned she was mixing her Lantus/regular and was told by her previous PCP that it was ok. She also was dosing her regular insulin based on sliding scale and had not learned carb counting.

Lesson Learned: These are areas that are the most important to assess. Never assume that a seasoned individual with diabetes is injecting without a problem, or has not been updated on the newer ways to manage their disease. It is important to review their technique to see if there is any new information they might benefit from as well as to confirm that their methods are sound.

Lynnette Hartwig RN, BSN, CDE

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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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This article originally posted 10 December, 2012 and appeared in  Safety and Error PreventionPatient ErrorsDiabetes Clinical Mastery Series Issue 114

Past five issues: Diabetes Clinical Mastery Series Issue 208 | Issue 748 | GLP-1 Special Editions September 2014 | Diabetes Clinical Mastery Series Issue 207 | Issue 747 |


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