Sometimes no matter what we do, disasters can just happen. This disaster comes from Dr. Aaron Vinik from the Eastern Virginia Medical School. “The most interesting diabetes disaster that happened recently, was a patient who was diagnosed with neuropathy secondary to B12 and B6 deficiency”….
As part of his treatment we had the patient begin therapy with B12 and B6 vitamins. He eventually ran out of the B6 (pyridoxine) tablets so the nurse practitioner cut the B12 (cobalamin) tablets in half so she could give him his B6!”
Lesson Learned: It is vital that we as practitioners ferret out misunderstanding and misconceptions by paying attention to anomalies and by always asking question. Though this particular circumstance was essentially harmless, a similar misunderstanding about a more potent drug could be disastrous.
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.