Hi all,

Although not surprising, I find it interesting that "the use of insulin has been associated with more medication errors than any other type or class of drug". (PA Patient Saf Advis 2010 Mar;7[1]:9-17.)

 

Anyone care to share some errors they are aware of? And, if you know how to prevent, or change the way we do things to prevent these, please let us know.

 

For example, I am aware that sometimes insulin is prescribed using the U-100 as part of the order. For example, a prescriber may write, Lantus U-100, 30 units subcutaneously at bedtime for a patient. The patient, or person administrating it gave 100 units rather than 30. How do we correct that? Since Lantus is and always has been U-100, and for that matter, other than Humalin R U-500 was* to my knowledge the only insulin that is not U-100, leave off the U-100.

 

I think we've all had the experience of people confusing their rapid acting insulin with their long acting insulin. I appreciate the companies helping with making the size and color of pens and vials different. 

*I thought U-40 insulin and the syringes were no longer on the market. WRONG! They use it in

cats 

http://bit.ly/rL4hmX

 

Please share experiences you are aware of, and how to prevent these with us.

Thank you!

EnJOY!

 

Joy

 

I think it would be nice if all the rapid acting insulins had a certain color vial and all the long acting had a different color vial.  For example, all the rapids are red, all the long acting are blue, etc.  So it is universal across brands.  But I have had patients tell me that they picked up the wrong color vial and gave it as the wrong insulin anyway.  For example, their rapid is marked with a red pen but they still picked it up and gave their basal insulin dose with it.  I think storing them in 2 different areas of the fridge or house is helpful too.  Mostly, think before you administer!  Check, and re-check.  What is the rule in carpentry?  Measure twice and cut once.  In diabetes insulin administration it should be measure twice and inject once.    

That is a great idea.  I think the most common patient errors are mistaking rapid for basal and double dosing.  I also have developed several overlapping methods for separating my basal and rapid, but additional cues can only help.

Great Idea!!!

Thanks for bring up this topic, Joy. I think that the suggestions that have been made are very good ones.  Most people start out being very conscientious when taking a new medication. As time goes on, many people tend to get a little more casual about the little details...all of which are very very important when insulin is the medication in question. 

There is more to accuracy than just drawing up the dose. To get consistent results from a specific insulin several issues need to be addressed:
1. I have found most people do not thoroughly mix cloudy insulins each time before they draw up a dose from a vial. The same is true if the cloudy insulin is in an insulin pen. The insulin in the pen has to be thoroughly mixed before each use.
2. Checking for air bubbles in the syringe or insulin pen cartridge. This is especially important for pediatric doses. Also air bubbles in insulin pump tubing prevents consistent delivery of insulin.
3. The HumulinR U-500 insulin seems to be advocated with greater frequency for obese type 2 diabetes patients who seem to need very high doses of insulin. Humulin R U-500 insulin has less chance of being confused with Humulin R U-100 insulin since the only way you can get Humulin R insulin now is in Walmart as Humulin ReliOnR U-100 insulin that is packaged very differently from You need to use a U-100 insulin syringeEli Lilly's R U-500. The big problem with U-500 Humulin R is that there is no U-500 insulin syringe. 

I think that it is an amazing idea. I think that not only patients make mistakes but practitioners have the potential to make errors as well. Having everything color coded would be a visual prompt that would, hopefully, prevent the person, or practitioner from making an error.

It would also be helpful to have the vials/pens not only color coded but a raised symbol on the bottom like those on the Novolog Flex Pens so someone who was visually impaired or color blind could differentiate that a dash meant a long-acting basal insulin, and a dot meant a rapid-acting analog.

Donna, that is a brilliant idea...you should patent it. People have become millionaires with less brilliant ideas!

 i will take this adviced and share to my colleagues,thank you so much. 

Hi Pat,

The information about U-500 is extremely helpful.  I found what follows to be extremely helpful from the link you recommended http://www.uspharmacist.com/content/s/126/c/20822/

Once again, thank you for your continued contributions.

EnJOY!

Joy

presentdiabetes.com Contributing Nurse Editor

 

Potential Problems and Recommendations

It is not difficult to imagine the potential for errors or adverse effects when utilizing concentrated U-500 insulin. Fortunately, due to the highly insulin-resistant nature of U-500 patients, hypoglycemia is not a common problem.² In fact, underdosing and hyperglycemia materialize when patients are admitted to the hospital and inpatient staff are reluctant to prescribe U-500. For users of U-500, however, the potential for hypoglycemic reactions 18 to 24 hours after injection is a concern due to the drug’s delayed kinetics.¹² Monitoring for this phenomenon with adjustments to dose and schedule is important. 

One area for mishap surrounds the type of syringe utilized. Standard insulin syringes are marked for U-100, so when filled with U-500 insulin, the dose injected does not equal the units printed on the syringe. The doses are, in fact, five times greater. Patients may misinterpret their dose of U-500 insulin as 40 U, for example, when in reality they are injecting 200 U. To avoid ambiguity, express the dose in volume and use tuberculin syringes marked in volume. Tuberculin syringes may not be as readily available as insulin syringes, and some insurers may not regard them as diabetic supplies.¹² Regardless, pharmacies should stock 0.5 and 1.0 mL tuberculin syringes with 30-gauge, 0.5-inch needles and provide them to patients using U-500 insulin.

Here is some additional information regarding the use of Humulin R U-500

Humulin R U-500 comes in a 20ml vial  

Caution: Humulin R U-500 should only be administered by subcutaneous injection

Ø  Use extreme caution in measuring the dose

Ø  Action Profile is different from Humulin R U-100

Ø  Action profile of U-500 Humulin R is:

Ø   onset of action: within 30 minutes

Ø  Duration of action: up to 24 hours

Common side effects of Humulin R U-500 include:

Ø   Skin thickening or pits at the injection site (lipodystrophy). Change (rotate) where you inject your insulin to help prevent these skin changes from happening. Do not inject insulin into this type of skin. Do not inject into the exact same spot for each injection.

Ø   Injection site reactions (local allergic reaction). Symptoms may include: redness, swelling and itching at the injection site. Tell your healthcare provider if you have skin reactions that do not go away.

When administering Humulin R U-500

Ø  If U-100 insulin syringes are used, since their markings are in units and are designed and intended for use with the less concentrated U-100 insulin products, it is extremely important to explain the amount of Humulin R U-500 insulin to be administered in both actual dose and with specification of “unit markings” on the U-100 syringe.

Ø  If tuberculin syringes are used, since their markings are in volume (mL), the actual amount of Humulin R U-500 should be explained in both actual dose and with specification of volume (mL

Conversion information using both U-100 insulin and tuberculin syringes to help avoid dose confusion.
Humulin R U-500 dose (units)	U-100 insulin syringe (unit markings)	Tuberculin syringe (volume in mL)
25	5	0.05
50	10	0.1
75	15	0.15
100	20	0.2
125	25	0.25
150	30	0.3
175	35	0.35
200	40	0.4
225	45	0.45
250	50	0.5
275	55	0.55
300	60	0.6
325	65	0.65
350	70	0.7
375	75	0.75
400	80	0.8
425	85	0.85
450	90	0.9
475	95	0.95
500	100	1.0
Dose (actual Humulin R U-500 units)	Divide dose (actual Humulin R U-500 units) by 5	Divide dose (actual Humulin R U-500 units) by 500

 

From http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=55530#s29

 

We have made many errors at our house!  We use sharpie markers and marke the top of the humalog vial with red slashes, the regular with black and the lantus is plain.  That way you can see the top as you draw it up.  My daughter has also been drawing up insulin to take with her for lunch and accidentally injected it.  We usually give fast acting in her stomach and arms (legs only if she is high and we want intermuscular) and levemir in her backside and occasionally we will mix up locations.  Thats is not a big one.  Occasionally we will give the wrong dosage and occasionally we will miss the time for the dose.  That is all i can think of right now, but I am sure we have made many more!

I think the charts included on u 500 insulin are VERY confusing which is why we see so many people making potentially dangerous mistakes.  If you look at the chart above that Pat Linekin re-printed from a reliable source I am certain, knowing Pat's ethics and professionalism, it could look to the patient as if they needed to draw up 25 units of U500 Humulin, which would in fact give the patient 125 units of insulin.  The first column, labeled:  "Humulin R U500 dose (units)", should I believe, actually say:  Intended dose.  The second and third columns should say:  U 100 syringe--DRAW TO, and tuberculin syringe (volume in mL)--DRAW TO.  I strongly fel that they way the columns are labeled contributes to the problem.

I have a fair amount of experience with patients using U500 insulin, and many have made these unintentional errors.  As you point out, Joy, thankfully the basic state of insulin resistance that accompanies the use of U 500 insulin helps save patients from having these unintentional errors become lethal ones.

All good points, Donna. Whoever originated the dosage chart at the NIH was most likely not a registered nurse....at least I hope not.

Here's more examples of insulin administration errors:

I had a T1 pt.... who by accident of course.....injected 30 u of her rapid-acting insulin at bedtime instead of her 30 u of basal.  

She fortunately recognized her mistake as soon as she pull the needle out.  Rather than going to an ER, she and her husband stayed up all night with the goal of:  eating tons of sugar, candy, etc. to get and keep her BG up, and repeatedly check her BG a gazzilion times over a 6 hr period.

And then there was the pt who thought she was supposed to get her insulin by injecting it into the orange, and then eat the orange...!  Why? Bcause she saw the diabetes educator inject the insulin into the orange, so she just assumed you're supposed to then eat it!

 

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

 

Eat Well, Laugh Often, Love Much

I too had a pt that mistakenly took his fast acting insulin as his long acting.  He was a policeman on duty, and ended up with a low blood sugar leading to an unconscious reaction.  He was working evenings, and was alone.  Due to this error, it was then mandated that he be in a cruiser with 2 people on days.  In the long run, he was happier to be on days.  Made me wonder if it was on purpose to get switched....but given that he put himself at risk, I gave him the benefit of the doubt and said it was an error. 

 

Mary Ann, I am still laughing at the picture of the orange being used to demonstrate injecting. I know it was used a lot in the past, but I am sure some still do teach it that way.

 

I have found it better to either have a person new to insulin inject an actual insulin dose (if the instruction time coincides with the need for insulin),or at least draw up some saline and inject it into the abdomen....it is, after all, the needle prick that terrifies people...they soon relax after experiencing an actual injection and find out it is not so bad after all.

When I worked in the inpatient setting and sent patients home w/ insulin pens, we used Lantus for our basal insulin and NovoLog for the pranidal/correction insulin. So I provided the following:

Lantus is in the Light (gray) pen--It Lasts the Longest so it's the Largest dose

NovoLog is in the Navy pen-- Needed w/ Nutrition

So if I were choosing colors.... I would make the colors coincide w/ their use.

Long acting Levemir or Lantus--Lilac color pen??

But the pranidal insulins do not all start w/ the same letter... so

Aspart, HumaLog, and NovoLog??? H for Hungry? A for Additional insulin w/ meals, N for nutrition... but what color would work?

Roxy

Hey Roxanne,

I LOVE the clever way you used "word smithing" to help pts remember the difference between Lantus (all the "L's") and Novolog (all the "N's") to prevent a disastrous error!

We are of one heart and mind....I do this all the time with key DSME behaviors across the spectrum of care.

Did you see my recent post from this past weekend?  

Mary Ann's Musings....Patient A.C.T.T.I.O.N. Steps for SMBG.

Check it out!

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

I saw a patient recently who truly illustrated the importance of observing a patient's injection technique prior to discharge from the hospital.  He had been re-admitted to the hospital only three weeks after being discharged.  I had not seen him on his initial stay in my facility but was asked to see him by the medical resident when he was re-admitted for persistent hyperglycemia, followed by hypoglycemia once he was treated in the hospital.

On his first admission, he was changed from oral hypoglycemic agents to insulin (Lantus) at bedtime, in addition to his oral agents.  While an in-patient, the nurses had been giving him his insulin and they had used an insulin vial and syringe rather than the Lantus SoloStar pen which we do have available in my facility.  No one had him self administer an injection prior to discharge.  Because he had good medical insurance, he had been prescribed the Lantus pen, and the appropriate pen needles.

When I asked him to demonstrate for me what he was doing with his insulin pen, ultilizing a saline pen, he appropriately attached the pen needle, and then did something I hadn't seen before.  He opened his mouth and used the pen to direct the flow of insulin (saline in this case) into his mouth.  Because this wasn't a vial and syringe which he had observed in the hospital and was a totally different device, he thought you took this orally and the purpose of the needle was to direct the spray into his mouth.

Needless to say, this did nothing to lower his fasting glucoses values and was why he became hypoglycemic when we upped his original prescribed dose, which he had actually never received.  The adage, a picture is worth a million words is so true.

 

Wow!  that is amazing.  I like to Wow my students with these kind of stories.  Thanks for sharing!  I think it was listed on PRESENT if not in this thread about the man that was injecting his insulin into an orange and then eating the orange thinking that was how he was supposed to do it.

I like to have the person I am teaching 'teach back' the method prior to leaving.  If they actually give themself a shot or check their blood sugar during the 'teach back' that is even better-then they have already done it and don't have that as an excuse to not do it again!

 I saw a patient that had been discharged from hosp on insulin for the first time.  When my colleague saw him post-hospital f/u his BGs were elevated so she gave him an injection in the office that brought his BGs down and then increased his dose.  When he returned on f/u his BGs were out of sight.  It was like he wasn't taking the insulin at all.  So I had him show me how he gave himself an injection.  He appropriately pushed air into the vial but then just waited for the insulin to fill the syringe.  In other words, he didn't DRAW any insulin out of the vial, he just held the vial upside down w/the syringe inside of it waiting for it to fill itself.  What was 'filling' was the air he had previously put into the vial.  So he had been injecting air.  When I pointed out the mistake he said he remembered being shown how to DRAW out the insulin but had just forgotten.  

It was an eye opener.  When in doubt, have them demonstrate!

 

Thanks for sharing those real life examples,  Donna & Micki.

I think that in addition to return demonstration when initiating insulin ...or any other injectable medication...it is important to give a printed pictorial instruction sheet to the patient that reinforces the instruction that you give. It protects you legally and is a good reinforcement.  Information overload is often what we have to deal with when a patient is being prepared for discharge...we can't count on memory alone.

 

This was a good discussion. I use the BD insulin starter kits. They have a wonderful step-by-step pictorial instructions that I use with initial instruction and demonstration and then it goes home w/ the patient. Hopefully this process of seeing it, doing it, and then the reinforcement of taking the booklet home will help to prevent insulin administration errors.

Roxy

As educators, I KNOW we all give those backup written instructions.  In the case, of the patient I described who was "swallowing" his insulin, he had been seen by one of the bedside nurses who didn't give him the BD Take Home kit, which I have put on all the units, but they had run out and the RN didn't have the additional time to come to my office to get more. 

This is a constant challenge for me in the in-patient world where I have quite literally about 250 to 300 in-patients daily with diabetes.  I have trained 25 bedside nurses with 12 CEUs to be "diabetes Nurse Champions" but he didn't even have the opportunity to see one of them. The volume of patients is my medical center daily, greatly exceeds the amount of staff available to help, so this problem is growing as is our incidence of diabetes and obesity.

One of the things I say to patients in my facility to help them remember which insulin is which is:  "What color is your pen?"  (I take off the cap, and ours is currently a Novolog Flex Pen, so it is orange.  "Orange is a food, so this is the insulin you take before you sleep".  Then I show the Lantus pen and say "This pen looks a little sleepy doesn't it?"  "This is the insulin you take before you go to sleep."  I developed this when a patient of mine did the same thing one of you mentioned, I think Mary Ann,  of taking the rapid acting insulin before bed, and her daughter found her the next morning unconscious.

Insulin use in the elderly, is the second leading medication cause of hospital admission secondary to dosing inaccuracies as well as physiologic challenges particularly in light of decreasing renal function.  Because 35% of insulin is catabolized by the kidney, it's a set up for insulin overdose and hypoglycemia.

It is exactly right! I have a patient who by mistake took Humalog dose as a basal lantus insulin. He ended up in  ED. So, after that I am very careful in emphazise to the patient and family to place the meal time insulin in the kitchen, dinning room or just have it in a marked place where only the meal time insulin should be... Long acting insulin should be in the bedroom, bedside table, et.  Also I sometimes labeled Humalog,Novolog as "only with meals". It must be a change on this from the manufactures so there will be one more way to avoid errors. Thanks,MM

 

I,too, have had a patient confuse his rapid and basal insulins by accident. This patient actually made the error twice, having to go to the er for treatment both times. To help prevent the mix up, i actually like to see my patients use a vial and syringe for their basal insualin ( as long as they are able) and a pen for the rapid. The pen is most useful for making it convenient to take thie meal dose when they are out at a restaurant or at work, but they are usually at home to take the basal. The convenience of a pen is less important for that dose. In my opinion, this provides a difference that makes it nearly impossible for them to mix up the doses in error. Often, these errors are not from a lack of knowledge, but are skill based errors, meaning, you have done the task so many time, you do it on autopilot. When the patient needs to have pens for both types due to vision or dexterity issues, I caution them to keep the pens in two locations as a safety barrier. Tracy

Thank you Martha,

What a simple common sense way to approach this. The bedtime or long-acting in the bedroom, and the meal-time/rapid acting in the kitchen.

This makes a lot of sense to me. And, I think it will to patients.

Thanks for the tip!

EnJOY!

Joy

Nurse Editor, presentdiabetes.com

 

Hi Tracy,

I think what you are teaching makes a lot of sense too. I've wondered the need for the pen for the basal insulin when only taking once a day, and when at home. I agree, using syringe and vial for long acting, and pen for rapid acting should decrease the amount of error. And for those who have difficulty drawing up insulin, using Martha's approach seems very reasonable. As you mentioned, you also tell them to keep them in separate places.

Thank you!

EnJOY!

Joy

Nurse Editor, presentdiabetes.com

 

Hi Joy

First of all, thank you for starting this conversation...what an important topic!!! It has heightened the awareness of all of us.

 

Thank you also to my wonderful colleagues for sharing real life examples and solutions.

 

It surely is a problem that the new long acting insulins are clear......especially for the people who have had diabetes a long enough time to remember when all long acting insulins were  cloudy and only short acting insulins were clear.