Description of Event or Problem · 1
THIS IS A REPORT REGARDING THE NEED FOR SAFETY DEVICE - APPROPRIATE INSULIN SYRINGES FOR USE WITH U-500 REGULAR INSULIN -500 UNITS/ML- WOULD ELIMINATE DOSING CONFUSION AND COMMUNICATION CONFUSION BETWEEN PATIENT, CAREGIVERS, AND HEALTHCARE FACILITIES. -1- MISS-COMMUNICATION AROUND PATIENT'S U-500 CONCENTRATED REGULAR INSULIN DOSE BEGAN UPON PATIENT'S LAST DISCHARGE FROM HOSPITAL IN 2009. PHYSICIAN WAS VERY SPECIFIC IN HIS DISCHARGE SUMMARY NOTING THE FOLLOWING: "HUMULIN REG U500: NOTE THIS IS MEASURED DIFFERENTLY THAN REGULAR INSULIN. GIVE 55 UNITS SUBCUTANEOUS WITH BREAKFAST -0.11 MILLILITERS EQUALS 11 UNITS MEASURED ON INSULIN SYRINGE-, GIVE 6 UNITS SUBCU WITH LUNCH -0.012 MILLILITERS EQUALS 12 UNITS MEASURED ON INSULIN SYRINGE-, GIVE 50 UNITS SUBCUTANEOUS WITH EVENING MEAL -0.1 MILLILITER EQUALS 10 UNITS MEASURED ON INSULIN SYRINGE- AND GIVE 20 UNITS SUBCUTANEOUS AT BEDTIME -0.04 MILLILITERS MEASURED ON INSULIN SYRINGE-." PHYSICIAN'S DISCHARGE INFORMATION WOULD HAVE BEEN IMPROVED IF IT WERE STATED AS FOLLOWS: "HUMULIN REG U500: NOTE THIS IS MEASURED DIFFERENTLY THAN REGULAR INSULIN. GIVE 55 UNITS SUBCUTANEOUS WITH BREAKFAST -0.11 MILLILITER MEASURED TO THE 11 UNITS MARK ON INSULIN SYRINGE-, GIVE 6 UNITS SUBCU WITH LUNCH -.012 MILLILITERS MEASURED TO 12 UNITS MARK ON INSULIN SYRINGE-, GIVE 50 UNITS SUBCUTANEOUS WITH EVENING MEAL -0.1 MILLILITER MEASURED TO THE 10 UNITS MARK ON INSULIN SYRINGE- AND GIVE 20 UNITS SUBCUTANEOUS AT BEDTIME -0.04 MILLILITERS MEASURED TO THE 4 UNITS MARK ON INSULIN SYRINGE-." -2- UPON DISCHARGE THE SAME DAY, RECEIVING CARE FACILITY PRODUCED PRE-PRINTED PHYSICIAN'S ORDERS FOR HUMULIN R 500 UNITS/ML AS FOLLOWS: "INJECT 11U SUB-Q W/BREAKFAST, INJECT 12U SUB-Q W/LUNCH, INJECT 10U SUB-Q WITH SUPPER, AND INJECT 4U SUB-Q AT BEDTIME W/SNACK" -PRINTED SIXTEEN DAYS LATER FOR THE FOLLOWING MONTH-, SO PATIENT WAS NOT RECEIVING CORRECT INSULIN DOSAGE AND WAS UNDERDOSED. ALSO FACILITY USES UNSAFE ABBREVIATIONS "U" FOR UNITS THAT CAN EASILY BE CONFUSED FOR A ZERO IN THE DOSE. OUTSIDE CARE FACILITIES AND PHYSICIAN'S OFFICES ARE NOT HELD TO THE SAME STANDARD OF CARE THAT HOSPITALS COMPLY WITH IN TERMS OF SAFETY STANDARDS PER GROUPS LIKE ISMP OR TJC. -3- WHEN PATIENT WAS READMITTED TO HOSPITAL THE SAME MONTH, MED REC INFORMATION FOR U-00 INSULIN DOSE WAS INCORRECT, AS REPORTED FROM CARE FACILITY. INSULIN IS CONSIDERED TO BE A "HIGH ALERT" MEDICATION, AS THE TERM IS DEFINED BY MULTIPLE SAFETY GROUPS. A CONCENTRATED FORM OF INSULIN, HUMULIN U-500, HAS BEEN AVAILABLE ON THE MARKET SINCE 1997. THERE HAVE BEEN NUMEROUS NATIONAL REPORTS OF COMMUNICATION PROBLEMS ASSOCIATED WITH THE PRESCRIBING, DISPENSING AND ADMINISTRATION OF U-500 INSULIN. MOST INSULIN IS DISPENSED AND ADMINISTERED IN A U-100 INSULIN SYRINGE. THE CONFUSION BEGINS WITH THE FACT THAT THERE IS NOT CURRENTLY A SYRINGE SPECIFICALLY DESIGNED TO MEASURE THE DELIVER A DOSE OF U-500 INSULIN. MOST OFTEN, PATIENTS DESCRIBE THEIR INSULIN DOSE IN TERMS OF "WHAT IS MEASURED ON A SYRINGE" AND NOT THE ACTUAL DOSE -IN UNITS- OF INSULIN BEING ADMINISTERED. WE ALLOW ONLY USE OF TUBERCULIN SYRINGES TO MEASURE U-500 INSULIN DOSES IN THE HOSPITAL, BUT PATIENTS MUST BE TAUGHT TO MEASURE THEIR HOME DOSES USING TRADITIONAL INSULIN SYRINGES DESIGNED FOR U-100 INSULIN. WE ARE SEEING A RISE IN THE USE OF U-500 INSULIN IN OUR COMMUNITY, AND PATIENTS WOULD BE BETTER SERVED AND SAFER IF THEY HAD SYRINGES AVAILABLE ON THE MARKET SPECIFICALLY DESIGNED FOR USE WITH U-500 INSULIN -500 UNITS/ML-.