Monday , October 23 2017
Home / Resources / Disasters Averted / Keep it Simple: Prescribe in Units

Keep it Simple: Prescribe in Units

Recently I was visiting with a patient during a diabetes education consult. The patient was on glargine and lispro sliding scale insulin. As I explained about sliding scale insulin, he related that during a previous admission to the hospital, he was given a prescription to take home for glargine insulin BID and one for lispro insulin which was to be taken three times a day before meals and that on the label it said “BMI 25-30″. He said no one explained to him what the prescription meant and when he picked it up at an outside pharmacy, the pharmacist also did not explain it to him. At home, he took his glargine as directed, then decided before a meal to try 25 units of lispro….

He said that he didn’t have any ill effects, but didn’t take any more that day. On another day, he decided to take 30 units before a meal, again with no ill effects. But then he said he just quit taking the lispro, though did continue glargine.

Fortunately for the patient, he was “non-complaint” with what he thought was the correct dose of lispro.

The hospital system has an order set which included correction insulin using lispro, based on BMI. This patient was on lispro correction BMI 25-30 scale while in the hospital and the doctor converted that specific order into a prescription at discharge. Doctors should be aware that it is inappropriate to convert the sliding scale based on BMI directly to a home prescription and that, if they desire a sliding scale, they should specify units of insulin to correspond with BG levels.

This could have been a disaster for this patient had he been more compliant with what he believed to be orders from the doctor.

Lesson Learned:

When providing information or a prescription to a patient, only prescribe in UNITS.

Rosalie Leman RN, CDE


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.

Report_Now

*****

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 Visa Gift Card worth $50.00. 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.

Copyright © 2012 Diabetes In Control, Inc.

←Previous Diabetes Disaster Averted 
The Pill Holder Error

Next Diabetes Disaster Averted 
Beware of Patient Gossip

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