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Diabetes Disaster Averted #8: Mail-Order Mix-Up

Nov 13, 2010

During a recent phone follow-up call to one of my patients a co-worker and I avoided a “Diabetes Disaster.” My patient told me that she had received her mail order refill for “ASPART” but the bottle didn’t look the same and she didn’t understand how to “dilute” it. I asked her to read the label to me. She had to spell it out. The drug was ASPARAGINASE.

Kathy Jacques, RN, CDE


Bottom Line:

This error could have happened at any pharmacy but it would be more likely to occur when there is not a pharmacist there to interact with the patient. These kind of errors can also be avoided if the patient has a picture or written description of the medication to compare their mail order refill to. Always ask detailed questions whenever there is the slightest confusion or ambiguity on the part of either the patient and/or the clinician. Confusion is a tell-tale sign that something may be amiss and should not be overlooked. – DJ



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