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Transcription Error Caught Just in Time

Jan 20, 2013

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.

I was on a plane from Tampa to Los Angeles and sitting next to me were two gentlemen who were business colleagues and friends. I overheard the one in the middle seat discussing that he had diabetes (he needed a seatbelt extender) and after trying pills for the past 6 months his doctor had put him on 70/30 insulin. He mentioned that his A1c was still over 9% and just last week the doctor had changed him to Lantus and Humalog on a sliding scale. As I listened to them talk I could not help hearing the doses he was talking about. According to what I heard the gentleman had been on 40 units of 70/30 twice a day and now he was on Lantus 20 units a day and Humalog 45 units at every meal. The doctor had given him a couple of sample pens and a prescription. He even mentioned how well this was working as he had actually had a low glucose reading.

Those numbers did not seem correct to me but as they talked he actually took out his new Humalog pen and dialed up to 45 units to show his friend how easy it was to use the pen and how small the needle was.

After about 30 minutes of listening to them talking about diabetes, insulin and monitoring I knew I had to say something. I introduced myself and explained I was a certified diabetes educator and wondered if he had the paper that the doctor had written the new dosing schedule on.

He showed me on his smart phone what he had programmed in and according to that it was correct. He then grabbed the script the doctor had given him to fill and sure enough he had it backwards. The prescription stated Lantus 45 units at bedtime and Humalog 20 units before each meal.

He was very thankful for the help I gave him and realized that I had probably saved him from severe hypoglycemia.

Lesson Learned:

We have all seen transcription errors made by our employees and others who interpret our medical records and commit them to electronic records. It only makes sense that we should look for the same problems to occur when our patients decide to use technology to help them remember dosing regimens.

Dave Joffe, BSPharm, CDE
Editor-in-chief, Diabetes In Control

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