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When Dealing with U100 Think Concentration Not Dose

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.

Lynn

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From the Institute for Safe Medication Practices ISMP.org

 

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