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Proliferation of insulin combination products increases opportunity for errors

From the November 27, 2002 issue

PROBLEM: We are concerned about a growing number of medication errors involving commercially available insulin mixtures. For example, just in the past few weeks we’ve received several reports about mix-ups between HUMALOG MIX 75/25 (75% insulin lispro protamine suspension and 25% insulin lispro injection [rDNA]) and HUMULIN 70/30 (70% human insulin isophane suspension [NPH] and 30% human insulin injection [regular] [rDNA]). One hospital alone reported several mix-ups where Humalog was erroneously prescribed as a 70/30 mixture (no such ratio exists) and Humulin 70/30 was administered in error. The nurse administered the dose from another patient's supply. In another hospital, an internist
prescribed "Humalog 70/30" and the pharmacist dispensed Humulin 70/30. Later it was learned that the internist wasn’t sure of the strength, but he intended for the patient to receive Humalog 75/25. In a third hospital, a nurse caught herself picking up Humalog 75/25, but plain HUMALOG (insulin lispro) was prescribed for her patient. The nurse mentioned that the packaging is very similar, including snap off caps that are the same color. The products also are available in pen devices that look alike. Finally, in another hospital, Humalog 75/25 was entered into the computer as plain Humalog. But luckily, the physician noticed the error when reviewing the electronic medical record.

Now, to add to potential problems, in late September, Novo Nordisk announced availability of NOVOLOG MIX 70/30 (70% insulin aspart [rDNA origin] protamine suspension and 30% insulin aspart [rDNA] injection) along with its currently available NOVOLIN 70/30 (70% NPH, human insulin isophane suspension and 30% regular, human insulin injection [rDNA]). The names and similar strengths of these combination products could cause confusion, and mix-ups between the different insulins could result in episodes of hypoglycemia.

SAFE PRACTICE RECOMMENDATION: Before making these products available, be sure to conduct a failure mode and effects analysis to detect potential problems and take action before an error happens. Although you should carefully select products for formulary addition, it may be impossible to avoid stocking these insulins since patients are likely to arrive in hospitals already controlled on one of them.

To reduce the likelihood of prescribing and dispensing errors, consider designing a preprinted order form for insulin that lists specific products, ingredients and component ratios. Have pharmacy dispense doses wherever possible in order to take advantage of an independent system of checks. If dispensed in vials, pharmacy should label them for individual patients rather than supply them as a floor stock item but a process for retrieving discontinued vials must also be in place. Place reminders about potential confusion in computer systems and storage locations. For drug selection screens, emphasize the word "*mixture*" or "*mix*" along with the name of the insulin product mixtures. You also may want to put stickers on the newer products to differentiate them from the established products. A physician’s daily review of current medication orders prevented one of these errors from reaching a patient. Although electronic medical records are not available in most hospitals, the ability to print out current medications from the pharmacy computer system usually exists. Such daily reviews are a very practical way to prevent errors.


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