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Patient’s “Non-compliance” Avoids Dangerous Error

Sep 30, 2013

Recently I visited a patient for a diabetes education consult. The patient was on glargine and lispro sliding scale insulin. As I explained about sliding scale insulin, he said 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 to be taken three times a day before meals. On the lispro insulin label was printed, “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. Then he said he just quit taking the lispro, though he did continue glargine.

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

Lesson Learned:

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.

Rosalie, RN, CDE

Copyright © 2013 Diabetes In Control, Inc.


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