After working with patients for 25 years I have learned that they can do the same thing right for a long time and then suddenly do something entirely different.
Because of this I make a habit of reviewing technique, be it glucose monitoring, self injections or the like. Recently an incident involving an active, well-intentioned patient reaffirmed the value of my habit. I was working with this patient and just to double-check I asked how often she opened a new bottle of Lantus. I did this because her dose was 100 units at bedtime. The patient replied that it usually lasted about a month. She did tell me that it seemed that the bottles were lasting a lot longer now than in the past, and she seemed to have extra bottles left at the end of each month.
I asked her to demonstrate her procedure and I noted how rapidly the syringe was filled and withdrawn from the bottle. I took a closer look at the syringe and it contained only about 30 units.
I asked her how her readings were doing and replied that they had been running much higher but she thought that was due to a cold.
The current dose was now less than a third of what she needed and she had no idea why she had suddenly started using only 30 units.
Teach patients to visualize the intended dosage under good light, hold the syringe up to eye level every time and make sure they have the correct dose posted somewhere to remind them. While the patient is observing that they have the correct dose, they can also use this moment to ensure that there are no air bubbles in the syringe.
Report Medication Errors to ISMP:
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