Monday , July 23 2018
Home / Resources / Disasters Averted / When Dealing with U100 Think Concentration Not Dose

When Dealing with U100 Think Concentration Not Dose

Dec 15, 2013

Courtesy of our partners at ISMP: One of my patients was asked to write out his home medications which he then did, including “U100 Novolin R insulin before meals and bedtime.” The nurse entered this into the E-chart for home meds as: “100 units of Novolin R ac/hs.” Because this didn’t sound right, I questioned the patient about this. He explained that he had just copied what was on the bottle, hence the U100. He said that he used the Regular insulin according to a sliding scale before meals and at bedtime….

When asked his usual dosage he said he never needed over 15 units. I explained to the patient the meaning of U100. But after interviewing a new graduate group of nurses I found they all interpreted what he had written as 100 units of Regular insulin also and did not know the meaning of U100. I now include this important piece of information in my orientation of all new hires at our hospital.

Lesson Learned:

Every medical professional needs to be educated about the different forms and strengths of insulin.  As insulin is the #1 item in the top medications that produce errors, educating medical professionals can prevent this.




From the Institute for Safe Medication Practices



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 
Avandia, Not Coumadin – Coumadin, Not Avandia

Next Diabetes Disaster Averted 
Pharmacists Making a Difference

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