Preventing Insulin Errors: Risk Reduction Strategies
From our partners at the Institute for Safe Medication Practices (ISMP): Organizations should strive to identify system-based causes of errors with the use of both insulin vials and insulin pen devices and implement effective...
U-500 Insulin
From our partners at the Institute for Safe Medication Practices (ISMP): Most insulin products are supplied from the manufacturer in a 100 unit/mL concentration. The insulin is then administered using an insulin syringe specially...
Displays on Insulin Products on Pharmacy Labels and MARs
From our partners at the Institute for Safe Medication Practices (ISMP): Most pharmacy-generated labels, both in acute care and outpatient settings, display the name and strength (i.e., concentration) of the drug on the same line.
Transcribing and Order-entry Errors
From our partners at ISMP: Among the wrong-dose insulin errors, 13.8% (n = 98) of the events involved breakdowns that occurred when transcribing orders, such as when entering orders into an MAR or a computerized order-entry system....
Ambiguous Orders Written by Prescribers
There has been much written about problems with handwritten orders for insulin, including the use of dangerous abbreviations or dose expressions and other shortcuts when communicating orders. How the use of the letter "U" to abbreviate...
Clarity in Insulin Coverage Orders, Part 2
From our partners at the Institute for Safe Medication Practices (ISMP):
Clarity in Insulin Coverage Orders
From our partners at the Institute for Safe Medication Practices (ISMP):
ISMP: IV Insulin Administration
From our partners at the Institute for Safe Medication Practices (ISMP), this week we have a review of IV Insulin Administration and two examples of what can go wrong when the correct procedures are not adhered to.
Wrong-Drug Errors Associated with Insulin Products
This week's Disaster Averted comes courtesy of ISMP.
There are numerous case reports in the literature that discuss the issue of wrong-drug medication errors with insulin products due to similarities in the...
Diluting Insulin for Infants
A 3-day-old infant weighing 1.3 kg was prescribed total parenteral nutrition containing 1 unit of regular insulin per each 327-mL bag.
Editor's Note, DCMS #131
Over the last seven weeks over 50% of the Diabetes Disasters Averted we have presented to you revolved around insulin errors. Our typical incident involves a medical professional finding an error just before it does severe harm to a patient....
Diabetic Emergencies, Diagnosis and Clinical Management: Hyperosmolar Non-ketotic Hyperglycemia, Part 1
Konstantinos Makrilakis, MD,...
ISMP: Updating Your High-Alert Medication List
Because insulin is at the top of the "High-Alert Medication List," we are presenting this updated article from our partner at ISMP (Institute for Safe Medication Practices).
Patients (and Caregivers) Must Demonstrate Insulin Injection Technique
A patient came into our emergency room recently with severe hypoglycemia (blood glucose of 34 mg/dl).
Accidents Will Happen But Damage Can Be Minimized
Over the years I have had many patients come into the pharmacy requesting a replacement bottle of insulin because they've accidentally dropped a bottle. Recently, a patient shared this experience:
Determining Medical History in an Emergency
I work in an emergency room and more than once we have had patients with diabetes come in with either severe hypoglycemia, or hyperglycemia and DKA.
Diabetic Emergencies, Diagnosis and Clinical Management: Sick-Day Rules in Diabetes, Case Studies
Konstantinos Makrilakis, Nikolaos Katsilambros
Insulin Pump Trainers and Training
An insulin pump trainer who worked with a pump company recently trained one of our patients in his home.
ISMP: A Clinical Reminder about the Safe Use of Insulin Vials
This feature article by our partner in diabetes safety, the Institute for Safe Medication Practices, summarizes the risks of insulin pen use in hospitals, the crucial importance of proper training for a safe transition to the use of insulin vials...
Changing Doses Can Be Confusing
A woman with newly diagnosed type 2 diabetes mellitus and also on blood pressure and anti-lipid medication was given prescriptions for: glucophage 500mg QD for one week, and then an increase to two 500mg tablets the second week.
Patient's Attempt to Increase Potency of Medication
Last week we had a patient come in to the pharmacy with a prescription for sildenafil 100 mg to be used as directed.
Grams versus Grams
As a diabetes educator and insulin pump trainer I request that my patients keep several days of food records prior to assessment visits.
Different Insulins Should Be Clearly Marked
This type of "Disaster Averted" has been sent to us a number of times and can be prevented by ensuring that your patients are correctly educated and prepared to avoid such events.
Transcription Error Caught Just in Time
Often as medical professionals we are around people that we could make a difference with and we are hesitant to do anything for fear of offering unsolicited advice, or liability issues.
The Most Common Error Made when Using an Insulin Pen
This type of error has been sent to us at least 60 times. So as a medical professional you should be aware of this issue when showing a patient how to use an insulin pen.
Multiple Safety Checks Missed Resulting in Double-dose Error
Several months ago I saw a patient with a 15-year history of type 2 diabetes.
Gastric Reflux Symptons Can Be Misread
John, 59 years old, was diagnosed with type 1 diabetes at two years of age.
Two Prescriptions But Only One Medication
Last week we had a patient new to our practice come into our office with a bag full of all her medications.
Maintaining and Monitoring Good Habits
After working with patients for 25 years I have learned that they can do the same thing right for a long time and then suddenly do something entirely different.
Longtime Insulin Users Can Still Make Mistakes
Recently I saw a type 1 diabetes mellitus patient who had been diagnosed in 1980 at 15 years old.
Insulin Pump Safety Measure
I was working with a patient who'd recently had a pump upgrade and although he said he didn't have any issues with infusion set changes, I urged him to change his set while I was present.
Inspecting Injection Areas
I had a patient recently who asked me to look at his abdomen as he said it was red and tender. He had been using this area for a number of years. His blood sugars were not well controlled as evidenced by an A1c of 9%....
A Fundamental, Pervasive Insulin Error Source
I recently met with a patient and his wife to confirm their understanding of a correction schedule based on his pre-meal blood glucose.
Insulin Pen Delivery Failures
I just encountered the second patient in the past six months new to using pens who was "taking" the insulin with the inner needle shield left on.
Insulin Timing and Hypoglycemia
Recently, I saw a patient who was a seasoned insulin user.
Educating Patients to Counter Prescription Fulfillment Errors
Recently a patient came to our diabetes center for education and to improve her control.
Educating Elderly Patients
Several years ago, I had a 70-year-old patient who was starting on an insulin pump.
Drug Induced Hypoglycemia, Police Assault and Incarceration Disaster
Complications go beyond co-morbidities for blind diabetes patient...
Changing Medications
At a recent support group meeting, a patient raised his hand and told me that he had been prescribed both Lantus and Levemir, and was taking them both at night.
Same Brand, Different Pens
Recently, a patient with an inexplicably high A1c was referred to me.
Why Patient Demo's Are Important
Recently, I met with a patient on Byetta 5mcg with a prescription for 10mcg as her continuation dose by a physician in the practice I work in.
Dialing in the Wrong Number
When you turn the dose selector to dial a dose of insulin using a Novo Flexpen, the number of units to be administered appears in a dose window.
Patient's Medication Re-organization Solves Problem
A clinic patient called to complain about hypoglycemia, fatigue, dizziness and a weight gain of 5 pounds in the last two weeks. The patient was on 500 mg Metformin bid and had purposely lost 40lb over the last six months with diet and...
Free but Costly
A patient in our comprehensive diabetes education program had received a meter set in mmoles/L from a durable medical equipment company.
Summertime Highs and Lows
Near the end of June, I volunteered to help out at a 10k race.
Regular or Diet?
Three weeks ago, on a Thursday, we had a patient in the ER at about 8:30 pm with a glucose reading of 675 mg/dl.
A Perfect Storm for Error
Several years ago, I was working for a hospital-based endocrinology practice.
Long-acting Insulin x 2
At a recent support group meeting, the topic was long-acting insulin glargine. During the discussion, a patient raised his hand to tell me that he had been prescribed both Lantus and Levemir, and was taking them both at night. I advised the patient...
Checking Everything Twice
We had something happen in our office recently that I had never expected to occur.
The Importance of Explaining Medications' Actions to Patients
We had a patient on metformin, and had started her on liraglutide, working her dose up to 1.2 mg/day over four months....
Concussion Patient's Drowsiness Not What it Seemed
I often read these disasters and think that it can never happen to me as I work as a hospitalist in Western Oklahoma. However I now know that it can happen to anyone and anywhere....
Be Very Specific When Instructing Patients on Insulin
At the diabetes center I work at, we have group classes for exercise which some diabetes patients attend often and are known to all the educators at the center.
Insulin Pens: Technology Is Not without imPENding Risks
With the use of insulin pens growing in the U.S., it's important to be alert to the increasing potential for errors as well, especially in hospitals....
When U is not Units!
One of my consults had written out his home meds which included, "U100 Novolin R insulin before meals and bedtime." The nurse entered this into the electronic chart for home meds as...
Insulin for DKA - Not Always a Good Choice!
We recently had a patient who was visiting her daughter in a small town in a Midwestern state....
Medical Residents and Real-World Experience
A few years ago, I was working in an ER when a patient was admitted who had accidently injected 60 units of Novolog instead of Levemir. The patient had called her daughter who had advised her to chew 10 glucose tabs, take 2 tablespoons of sugar,...
Insulin Storage and Refrigeration
I had an insulin-dependent type 2 patient who was on Solostar Pens of Glargine 65u hs and Apidra 18u tid plus sliding scale for glucose control.
The Dangers of Sharing Medications
A 63 y/o female insulin-using type 2 patient who had suddenly gone out of control was referred to me.
Checking the Electronic Records
I read last week's Disaster Averted and it made me realize how things that we assume are correct are often not - DJ
Our practice had recently converted over to electronic medical records and we had spent considerable time...
Beware of Patient Gossip
Recently we had a group of patients in the office for a shared medical appointment. I had been trying this idea to see if they could learn more than in a normal appointment. We started off the visit by having all of the patients introduce...
Keep it Simple: Prescribe in Units
Recently I was visiting with a patient during a diabetes education consult. The patient was on glargine and lispro sliding scale insulin. As I explained about sliding scale insulin, he related that during a previous admission to the hospital, he...
The Pill Holder Error
During an office visit with one of my 68 y/o white female patients, she was complaining of constant thirst and excessive urination. She also expressed concern that she felt tired all the time. I looked at the chart and found the patient was...
Insulin Pens: Getting the Basics Right
Of all our published Diabetes Disasters Averted, one error in particular keeps showing up: we have received more than 15 cases focused on the correct use of insulin pens. This week we have yet another addressing the importance of assessing a...
Diabetes Disaster Averted #76: Insulin Confusion
I recently had an elderly, ill gentleman discharged from the hospital, who was not a new diabetic, but new to insulin. He had steroid induced hyperglycemia, and would need a correction aspart coverage until his Prednisone was tapered off. He...
New and Unfamiliar Drugs
When Januvia first came out, I was called by legal affairs about a patient of another MD at the local university hospital whose house staff had ordered 1000 mg Januvia instead of 100mg. The drug was so new that the nurses did not know that...
Glucose Monitors from the Past
I was working with a woman with type 1 diabetes. She was in her 20's and pregnant for the first time. I saw her after she had already seen her OB doctor and nurse for education. While working with her on her meal plan, I asked about her blood...
Calculating Bolus Doses: Keep it Simple!
I have a well-established Type 2 patient who uses oral medication and is on a basal-bolus insulin routine. We have gone over all of the basics of diabetes self-management and how to use medications, and this education has been reinforced at...
Diabetes Disaster Averted #69: Take as Directed!
A patient was given a prescription for glipizide twice a day "as directed (ut dict)"….
Diabetes Disaster #68: FDA ALERT -- Insulin Pen Sharing
Insulin Pens and Insulin Cartridges Must Not Be Shared. The U.S. Food and Drug Administration issued an alert to health care professionals reminding them that single-patient insulin pens and insulin cartridges should not be used...
Diabetes Disaster Averted #67: The Cattle Syringe
A gentleman was referred to me for assistance in helping with glycemic control. He was a rancher. For the prior 2-3 years, his insulin type had been changed from NPH to Lantus and finally to Levemir in an attempt to help with his FBS control....
Editor's Note DCMS #66: Beware of Similar Medication Names
Last week I was walking in the OTC department in front of the pharmacy and I noticed a box of Fastin on the shelf. I was surprised by this as I knew that the RX version was phentermine 37.5 mg and could not believe that you could now...
Diabetes Disaster Averted #66: Beware of Similar Names
I work as a staff pharmacist at a community hospital in the Northeast. I received an order via POM for Nevirapine (brand = Viramune) 500 mg po BID. Since Viramune (an anti-retroviral medication) comes at 200 mg strength I decided to...
Diabetes Disaster Averted #65: Language Interpretations
I was a CDE in a small community hospital and served many women with gestational diabetes who were Hispanic. I saw a woman who I had followed during a previous pregnancy where she required insulin. She had received education about starting on...
Diabetes Disaster Averted #64: Long-Time Insulin Users Still Make Errors
I recently met with a patient to confirm his understanding of a correction schedule based on his pre-meal blood glucose. He'd been on insulin for more than 12 years. On the 70/30 correction schedule, he and his wife were both able to find the...
Editor's Note: AGEs, Errors and Teenagers
Over the past three issues we have focused on advanced glycation end-products (AGEs) -- how they are formed, what they can do, and why these compounds are detrimental to our patients' health. This week in our Homerun Slides, we are...
Diabetes Disaster Averted #63: Color Coding Discrepancy
Recently I was on a home visit with a client who was taking Novolin 30/70. She asked me why the insulin band on the cartridges in the fridge was a different color than what was in her pen. She told me the label on the insulin was...
Diabetes Disaster Averted #62: 'Double Dosage'
Several months ago I saw a patient with an approximately 15 yr history of DM2. He was seeing a primary care provider and an endocrinologist. On reviewing his medications I realized that he was taking Glucophage XR 750 tid and metformin...
Diabetes Disaster Averted #61: Double-Checking Dosages
A patient was admitted through the emergency room for a non-diabetes related event. At admission, it was reported that she took 36 units of Humalog twice daily. The primary care physician reviewed the current insulin dose, before he wrote the...
Diabetes Disaster Averted #60: Helping Patients Decipher Nutrition Labels
I had a patient who came in for instruction on carbohydrate counting in order to dose his insulin based on his carbohydrate intake. I instructed him on the use of food lists and food labels. When the patient returned...
Editor's Note: Pre-School Children with Diabetes
Have you ever had a patient who is a pre-school child with diabetes? Usually this means that the parents are trying to stay in control and the child wants more independence.
Diabetes Disaster Averted #59: Bedtime Prescription
I had a type 2 diabetic patient whose fasting blood sugars were all over the place. The patient was on 34 units of Lantus that she stated she took every night. After asking more questions I realized that on the patient's prescription for...
Diabetes Disaster Averted #58: Ask the Right Questions
We had a type 2 diabetes patient who was scheduled for surgery. The surgeon knew she was going to need assistance with this patient and contacted an appropriate medical doctor. The doctor suggested that the patient take only half of...
Diabetes Disaster Averted #57: Phone Orders Prone to Errors
An elderly patient was admitted from an ECF to a Medical Subspecialty floor. She was on Lantus 8 units every night at the ECF. The nurse called the MD for admission orders. He inquired how much insulin the patient was on at the ECF. The...
Diabetes Disaster Averted #56: Medication Adherence
I recently met with a Type 2 patient (Jim/52y/o) with an A1c of 9.5%. The first thing I did was to review his medications: he stated he was on 40u of Lantus BID, Glucophage SR 750mg , 2 tablets BID, and Victoza 1.8mg, Lipitor 20mg, and Aspirin...
Diabetes Disaster Averted #55: Medication Mix-up
An elderly patient noticed that his usually good control with a 70/30 insulin pen had diminished recently, and stopped by our diabetes education program to ask for help....
Diabetes Disaster Averted #54: New Infusion Set Hyperglycemia Puzzle
I had often been puzzled by statements, made by some of my patients who use insulin infusion pumps, such as, "I notice elevated blood glucose levels after I insert a new infusion set." This never made sense to me as a source...
Diabetes Disaster Averted #53: Insulin Incident
I recently spoke with a Certified Diabetes Care Educator about a particular patient whose "Diabetes Disaster Averted" demonstrated the need for patient education, including the awareness of when something's not...
Diabetes Disaster Averted #52: Heparin and Insulin Mix-Up
How can injectable heparin wind up in an insulin syringe? Your first thought may be a vial mix-up in which a nurse, pharmacist, or pharmacy technician accidentally drew heparin into an insulin syringe, believing it was insulin. But...
Diabetes Disaster Averted #51: Careful Listening Saves Lives
A few years ago, I was working as a Nurse Practitioner in an endocrinology practice. One of my longstanding elderly patients, age 82, called me to report that the paramedics had to come to her house because she passed out....
Diabetes Disaster Averted #50: How Long Should Insulin Be Used Once a Vial Is Started?
Diabetic patients treated with insulin, whether for type 1 or type 2 diabetes, are prone to often unexplained swings in their blood glucose. These swings can vary from dangerously low to persistently high levels. Most diabetic patients, and...
Diabetes Disaster Averted #49: Indication Can Prevent Errors
For a patient with known diabetes, a pharmacy technician typed the medication order in Figure 1 as "Lantus inject 80 units at bedtime," then dispensed 3 vials or 30 mL. The pharmacist read the order the same way while checking the...
Diabetes Disaster Averted #48: Lactose vs. Lactulose
I recently got a call at my office from a home healthcare nurse who was visiting one of my patients who was suffering from cirrhosis of the liver and experiencing high ammonia levels....
Diabetes Disaster Averted #47: Mixed Insulin Dosages Lost in Translation
I work in a large teaching hospital in the Northeast and recently had an order written for mixed insulin for a new admission that seemed very odd. One of our newer residents wrote an order for Humalog 75/25: give 9 units at breakfast, 7 units...
Diabetes Disaster Averted #46: When It's Too Hot to Handle
I recently had one of my long term type 1 patients on an insulin pump run into a big problem. She had been on an older pump for about 5 years and had recently changed brands because of the features of the newer pump….
Diabetes Disaster Averted #45: Pharmacist Follow-up Catches Insulin Oversight
An underweight 77-year-old white male with 20-year history of insulin-dependent DMT2 was admitted to community hospital's emergency department with fever, chills, irregular heartbeat, and infrequent foamy urine output. Alert but disoriented...
Diabetes Disaster Averted #44: Testing and Driving
A client had an A1C of 7.5% and her blood sugars were all over the chart. She had been coming for three months but had no explanation of the 37 to 300mg/dl readings. She stated that she never felt a low and could not understand...
FDA Warns Healthcare Professionals to Closely Monitor Patients with Diabetes Receiving Liraglutide Injections
The US Food and Drug Administration (FDA) warned healthcare professionals to closely monitor patients with diabetes receiving liraglutide injections (Victoza, Novo Nordisk) for thyroid C-cell tumors and acute pancreatitis....
Editor's Note: "Rotating the Site," Neuropathy Slides from Dr. Vinik, and More
It is not often that you get someone who wrote the ADA guidelines to share his slides with you, but this week our publisher, Steve Freed, asked his good friend Dr. Aaron I. Vinik, MD, PhD, FCP, MACP, Eastern Virginia Medical School, Strelitz...
Diabetes Disaster Plan
The Diabetes Disaster Plan aims to help ...
Managing Clinical Problems in Diabetes, Case Studies, Part 1
Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath
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Editor's Note: Saline Pen Problem, More on SMA's
Since insulin is new to many of our patients we often train them with saline. Many of them are trained with pens containing saline regardless of the manufacturer. These pens contain the same preservatives as regular insulin and smell exactly the...
Did You Know? Average Error in Insulin Measurement among Healthcare Professionals and Patients
In a study published in Archives of Internal Medicine, healthcare professionals were asked to draw up a total of 5, 10, or 30 units of insulin as either human insulin 70/30 premix or a combination of regular + NPH....
Our Long Journey Towards a Safety-Minded Just Culture, Part 2
Where We're Going: Human Error, At-Risk Behavior, Reckless Behavior, and A Promising Road Ahead
Our Long Journey Towards a Safety-Minded Just Culture, Part 1
Where We've Been: Punitive Culture, Blame-free Culture, and Just Culture
Before the 1990s, healthcare providers often...
Editor's Note: Patient Injection Mistakes, Incretin Slides - Part 2 and Long-Term Complications
This week I gave a lecture to the physician and pharmacist residents at one of our local hospitals and we were talking about the possible reasons that insulin would suddenly lose its effect on a patient. The pharmacist residents started...
Letter from the Editor: JP Morgan Conference, Eli Lilly-Boehringer Ingelheim News and More on Accidental Insulin Injection
Last week, many companies in the diabetes world were in San Francisco to present at the J.P. Morgan Healthcare Conference. Our own president, Andrew Young, was in attendance to see and hear what was going on, and to sum...
Editor's Note: Pets and Diabetes, Treatment Plans for Acute Complications and More Great Slides....
Does your patient have a dog or cat with diabetes? They may not know how an accidental injection of insulin may affect them. In this week’s Disaster Averted a pet owner accidently stuck herself with 5 units of insulin but lucklily was...
NCPS: Taking Aim at Medication Errors, Question 4
SF: Can you give an example of how the error reporting works?
KT: I have attached a NCPS Alert (in pdf format) from March 2009 on U 500 Insulin. This was the specific incident: "South West VA CMOP received an order for 40 units of U-500...
NCPS: Taking Aim at Medication Errors, Question 3
SF: What are the most common errors that occur at the VA in regards to diabetes patients and what has the VA done to prevent them from happening again?
KT: The data found within NCPS SPOT data is voluntarily reported so it is not a good...
NCPS: Taking Aim at Medication Errors, Question 2
SF: How do you minimize errors?
KT: Here is some more background to better understand the basis of our program. Neither the VA nor any other health care system can or will ever be able to "eliminate all errors." Patient safety programs...
NCPS: Taking Aim at Medication Errors, Question 1
SF: What is the VA's NCPS doing to change the medical safety culture so medical professionals will report all errors not just the ones that cause harm?
KT: We developed a confidential reporting system that allows VA caregivers to report not...
Letter from the Editor: U-500 Errors and 50 Ways to Prevent Diabetes
Next time the song lyrics, "Just slip out the back, Jack, Make a new plan, Stan, You don't need to be coy, Roy, Just get yourself free," from the Paul Simon song "50 Ways To Leave Your Lover" pop up in your head, why not substitute, "Snack on a...
Hyperglycemic Emergencies
Lana Kravarusic
Doctor of Pharmacy Candidate, University of Florida
Letter from the Editor, Sept. 5, 2010: Avoiding Errors When Switching Statins
As we move out of the dog days of summer more of our patients move into the donut hole of part D coverage and they come to us looking for less costly alternatives for their medications. Two of the biggest requests are for cholesterol-lowering and...
Letter from the Editor: Diabetes Disaster Avoided!
It seems like every time we get something new we forget about the old. Just last week I got a frantic call from an experienced, well-controlled, Omnipod patient who had not replaced her pod and had to inject insulin with a syringe. She was at lunch...
Preventing Medication Errors
Institute for Safe Medication Practices
tPA for Stroke Moving Out to 4.5 Hours:
Interview with Ralph L. Sacco, MD.
Strokes are increasing in our diabetes patients as they age and tPA has been the standard of care in the emergency room, but within 3 hours or forget it. Now...
A Message from Medtronic
To Customers Previously Using "Lot 8" Quick-set* Infusion Sets
Change at the FDA
David Kliff, Publisher, Diabetic Investor, has been looking at the President-elect’s recent appointments and keeps wondering who will be the new head the Food and Drug Administration. Whoever it is will have an interesting road ahead of...
Risks for Drug Induced Pancreatitis
With all the press lately about the incretin mimetics and pancreatitis our current intern, Jennifer Webb, PharmD Candidate, FAMU has taken a look at the facts, and compared the chances of pancreatitis among classes of drugs and how the risk of...
