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Disasters Averted

Disasters Averted are stories submitted by our readers and medical editors from direct experience in the field. Do you have a story? If your story is used, we will send you a $25 Amazon Gift Card! Submissions can be anonymous.

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All Insulins Not the Same

I recently had a home care patient who had been discharged from a skilled nursing facility with a prescription for regular insulin, and who was put on a sliding scale dosage. The patient was experiencing hypoglycemic reactions. I was called to see him to find out why he was having multiple …

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“Do Not Crush, Chew or Cut”


From the Institute for Safe Medication Practices (ISMP): When a patient is prescribed a timed release medication such as Glucotrol XL or Glucophage XR, clinicians need to ensure that the patients understand that they should not crush, chew or cut these pills. The medications must be swallowed whole.  In one case …

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High-alert Medications Lists

From the Institute for Safe Medication Practices (ISMP): High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. Use …

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ISMP: Similar Names But Different Actions: Potential Premix Insulin Prescription Errors

From the Institute for Safe Medication Practices (ISMP: Recently there have been reports of a mix up of mixed insulins.   The insulins involved were: NovoLog® Mix (analog) 70/30 (70% insulin aspart protamine suspension and 30% insulin aspart injection, [rDNA origin]) Novolin® 70/30 human insulin. Be prepared to address these potential …

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