Disasters Averted

Recently I assessed an 84 year old inpatient with diabetes for his insulin usage at home. In reporting his dosing he stated that after he checked his glucose before each meal he took the "first two numbers of the result," and made that his dosage for meal-time insulin. For example, if the …

I recently saw a patient for a diabetes follow-up and had just gotten her lab values faxed over. Her A1c came back at 9.6 despite the patient telling me that her glucose meter readings were much lower. She even showed me the meter and upon doing some averaging, it appeared …

One of my long term patients called my office because she could not figure out what was happening with her post breakfast glucose readings. She counted carbs and would typically have a 2 hour ppg of no more than 145 mg/dl but even though her pre-breakfast readings were around 110 …

When reviewing the medical record of a hospital patient prior to meeting with her for a diabetes consult, I noted that the doctor had ordered 46 units of Lantus to be given daily at bedtime. When I went in to visit with the patient, she had a very strong accent …

Steve Freed, Publisher, Diabetes In Control Errors in diabetes care are a common cause of complications and can result in disability and even death. The diabetes errors being reported are probably much lower than the number actually occurring. The problem of errors in diabetes care facing health care providers is now …

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 …

A 29-year-old woman with insulin-dependent diabetes noted a painful erosion at the site of the tattoo which she had gotten 7 days before. A culture isolated staphylococcus aureus confirming the clinical impression of staph. This diagnosis was not entirely unexpected, since patients with diabetes mellitus are predisposed to staphylococcal infection. An oral …

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 …

From The Institute For Safe Medication Practices: Insulin accounts for more than 10% of all drug mistakes. This drug class has been rated as having the most mistakes every year for the last 20 years. When the Pennsylvania Patient Safety Authority did a study of state hospitals focusing on medication errors, they …

This week we have a review adapted from information provided by Novo Nordisk of the most common insulin errors which include: Clinician errors Self-administration errors Self-monitoring errors Improper insertion techniques Bad drawing-up procedure Insulin timing Using the wrong insulin Miscalculating insulin sensitivity factor Using an incorrect carbohydrate ratio Not checking …