Home / For Your Practice / Safety / It’s Never Too Much

It’s Never Too Much

Jan 20, 2014
When sitagliptin (Januvia) first came out, I was called by our legal affairs department about a patient of another MD at the University of Penn whose house staff had ordered 1000 mg sitagliptin instead of 100mg. As the drug had just come out, the staff was not very familiar with the drug and its dosage. So, when reviewing a prescription, a nurse who was fairly new, did not recognize that it was 10 times the correct dose and they administered 1000mg of the drug….

Our legal department got very upset when the incident was reported and they called me because they were worried of their ‘exposure’ to a law suit. They were wonderfully surprised when I told them that the safety profile is such with sitagliptin that a patient gets no undue side-effects or low sugar with even ten times the recommended dose.

Lesson Learned:

Whenever prescribing or dispensing a new drug or one that you are not familiar with, you need to check its package insert or get more information about the recommended dosages, contraindications with other medications or disease states and side effects.

Dr. Stanley Schwartz (Board Member for Diabetesincontrol.com) has been awarded the honor of being a TOP DOC by Philadelphia Magazine many times over the years, including 2009, 2010, 2011, 2012 for the treatment of diabetes and metabolic syndrome. For over 32 years, Dr. Schwartz was an Associate Professor at the University of Pennsylvania, most recently directing the Diabetes Program at the Philadelphia Heart Institute, becoming Emeritus Associate Professor in 2011. Now Dr. Schwartz is seeing patients at a new private practice in Ardmore, PA.

Copyright © 2014 Diabetes In Control, Inc.


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.



And if you have a “Diabetes Disaster Averted” story, please also send it in separately to Diabetes In Control. If we use it you will receive a gift card worth $25.00. Click here to let us know the details. (You can use your name or remain anonymous if you prefer.) Please note that ISMP is not associated with this gift card promotion. 

←Previous Diabetes Disaster Averted 
Patient’s Careful Documentation Saves Her Time & Money

Next Diabetes Disaster Averted 
Ask the Right Questions

For the complete list of Diabetes Disasters Averted, just follow this link.