humulin-s and Drug-Overdose

Topics: Diabetes Mellitus, Type 2; Drug Overdose; Humans; Insulin, Regular, Human; Male; Medication Errors; Pharmacy Service, Hospital

Topics: Diabetes Mellitus, Type 2; Drug Overdose; Humans; Insulin, Regular, Human; Male; Medication Errors; Pharmacy Service, Hospital

Modifications made to medication-use processes after an overdose of U-500 regular insulin are described.. After a medication error occurred with U-500 regular insulin, a multidisciplinary team of physicians, nurses, advanced-practice nurses, and pharmacists was created to review and improve the ordering, dispensing, and administration processes associated with U-500 regular insulin. The group determined that current safety practices for managing insulin were inadequate. New safety processes specific to U-500 regular insulin were developed and implemented. Vials of U-500 regular insulin are no longer dispensed to nursing units and are stored only in the pharmacy and separated from other insulins. The ordering of U-500 regular insulin is limited to the endocrinology service, and all orders are written using a specialized U-500 regular insulin order set. The option for i.v. administration for U-500 regular insulin was removed from the pharmacy order-entry system; thus, only the subcutaneous route is entered by the pharmacist. In addition, patient-specific doses of U-500 regular insulin are prepared in the pharmacy using only tuberculin syringes that require a double check by two pharmacists. These syringes are delivered to patient care areas in a bag distinguishing the medication as "high alert." One last safety check involving a two-nurse check at the bedside to confirm correct medication administration is performed. Lastly, patient education material specifically for U-500 regular insulin is available online.. A multidisciplinary team recommended modifications to the medication-use system regarding U-500 regular insulin after review of a medication error. No errors involving U-500 regular insulin have been reported since implementation of the changes.

Topics: Aged; Diabetes Mellitus, Type 2; Drug Overdose; Humans; Insulin, Regular, Human; Male; Medication Errors; Patient Care Team; Pharmacy Service, Hospital