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[IP] And we question doctors' decisions...

>From Voice of the Diabetic:


"To err is human," the Romans said. Sometimes we humans do very strange
things -- and the only reason others are not hurt by our inattention, is
because somebody caught on in time. There is a moral to the following story:
Check and question!

The following is from ISMP MEDICATION SAFETY ALERT, published by the
Institute for Safe Medication Practices (www.ismp.org) Used with permission.

Although doctors may mean well, one manner that's being used to order U-500
insulin can lead to serious medication errors. Recently, an endocrinologist
wrote an order for 25 units of U-500 insulin to be given in the morning.
With 500 units per mL of insulin in U-500 vials (versus 100 units per mL in
U-100), nurses correctly calculated that the volume needed for a 25-unit
dose was only 0.05mL.

A call was made to the physician, to ask about changing to U-100 insulin,
for more accurate measurement. The doctor said that he'd actually wanted his
patient to receive 125 units. He simply thought it would be easier for the
nurses if he prescribed "25 units," knowing that the "25 units" mark on a
U-100 syringe would actually measure 125 units, when U-500 insulin was used
with the U-100 syringe!

In another case, a physician changed a patient's insulin to U-500, and
prescribed 5 units at noon and 8 units at dinnertime. As in the first case,
the doctor meant for the nurses to use a U-100 syringe to prepare these
doses of U-500 insulin. Thus, he intended his patient to actually receive 25
units at noon, and 40 units at supper.

Unbelievable? It's true....
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