Monday , July 16 2018
Home / Resources / Disasters Averted / Sometimes Is Not the Same as Always

Sometimes Is Not the Same as Always

Nov 24, 2013

One of our patients returned recently to our office for a Continuous Glucose Monitor (CGM) download and a review of his food log. At an earlier visit he had experienced a hypoglycemic reaction. Just as before, the patient was in a hurry to get to the appointment and had only eaten 1 piece of toast. When we checked his fingerstick blood glucose, it was greater than 200. The patient declared, “This is exactly what I was telling you. Even when I take my insulin it remains high sometimes for no reason.”…

I asked to see the insulin pen that he had used that morning. When we removed the cap I noticed that the needle was already on. The second thing I noticed was that the breakfast insulin dose remained dialed into the dosing window. The patient and his wife were very upset. They believed that he “always” gave his mealtime insulin.

For the future he committed to using a new needle for each injection, to dispose of the needle after each use, and to not store his pen with the needle attached. His wife said that she would be conscious of not interrupting him when he is preparing to take his insulin. Hopefully future “Diabetes Disasters” will be averted with this patient’s commitment to best practices for using an insulin pen device.

Lesson Learned:

Patients are not always correct even when they think they are. Keeping a log can help prevent missed doses.

Cynthia RN, CDE, Patient Education Manager

Copyright © 2013 Diabetes In Control, Inc.


Report Medication Errors to ISMP:

Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.



And if you have a “Diabetes Disaster Averted” story, please also send it in separately to Diabetes In Control. If we use it you will receive a gift card worth $25.00. Click here to let us know the details. (You can use your name or remain anonymous if you prefer.) Please note that ISMP is not associated with this gift card promotion. 

←Previous Diabetes Disaster Averted 
The Power and Dangers of Advertising

Next Diabetes Disaster Averted 
Influenza Vaccine – Shake Well!

For the complete list of Diabetes Disasters Averted, just follow this link.