Dosing Error Due to Misinterpretation

Aug 3, 2021
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Make sure you understand what the patient is really saying to avoid a dosing error….

When reviewing the medical record of a hospital patient before meeting with her for a diabetes consult, I noted that the doctor had ordered 46 units of Lantus to be given daily at bedtime. However, when I went in to visit with the patient, she had an extreme accent, and upon asking her to tell me how much insulin she had been using at home, she replied, “I take four to six units of Lantus. At night.” Alarm bells went off in my mind, and I asked her to repeat that to make sure I heard her correctly.

A few minutes later, the hospitalist walked into the room, and I explained what she had told me. It is evident that with her accent, the admitting doctor had misunderstood what she had said about her home dose. The hospitalist quickly discontinued the Lantus dose ordered by the admitting doctor and entered a more appropriate dose for the patient.

Lesson Learned:

When doing medication reconciliation, health care providers must make sure that they understand precisely what the patient is saying. If necessary, information should be obtained through interpreters.

Rosalie Leman, RN, BSN, CDE

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