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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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