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Preventing Medication Errors

Institute for Safe Medication Practices

Could this error happen in your practice?

Wrong insulin concentrationA new nurse working in the emergency department of a small community hospital offered to help a colleague who had received an order for an insulin infusion. The pharmacy was closed, so the infusion had to be prepared in the emergency room.

The nurse followed concentration information contained in a monograph for insulin appearing in a published nursing drug reference that was chained to the automated dispensing cabinet. As per the monograph, she prepared the infusion by placing 500 units of regular insulin in a 100 mL bag of normal saline. Unfortunately, being new, the nurse was unaware that the standard concentration for insulin infusions at the hospital was actually 100 units of insulin in 100 mL of normal saline. Although the infusion bag was properly labeled, the concentration was never discussed during the handoff to the receiving nurse.  

The standard concentration for insulin infusions was well known to the more experienced nurse, but unfortunately for the patient, this drug information was buried in an old and outdated insulin policy on a shelf outside the medication room; thus not readily accessible to the new nurse. The experienced nurse caring for the patient proceeded to administer a bolus dose of 10 units of regular insulin as ordered and started the insulin infusion at 2 mL/hour on the infusion pump (which she believed was 2 units per hour but was actually 10 units per hour). It was only after the patient became symptomatic that they recognized the error.

Ideally, pharmacies should prepare infusions that are not commercially available but in the absence of pharmacy services, prepared infusions, especially high alert drugs, should be independently checked by another individual, at least during a handoff. Hospital-approved drug guidelines for IV admixtures likely to be prepared outside the pharmacy should also be readily available for reference and personnel should receive a briefing about them during employee orientation. “Smart” infusion pumps may not be capable of preventing an error like this unless the person hanging the infusion and setting pump flow rates reads the label to identify drug concentration.  

Institute for Safe Medication Practices