A 3-day-old infant weighing 1.3 kg was prescribed total parenteral nutrition containing 1 unit of regular insulin per each 327-mL bag. A pharmacy technician mistakenly added 1 mL of regular insulin (100 units) rather than 1 mL of a pharmacy-prepared dilution of 1 unit/mL regular insulin. The mistake was caught 2 hours later when the infant’s blood glucose measured 3 mg/dL. Rapid treatment with dextrose boluses ensued, and the blood glucose returned to normal within 12 hours.[1]
Fonte: Medscape CME
Errors Associated With Insulin Therapy
Healthcare professionals regularly care for patients with diabetes, a condition resulting in hyperglycemia due to inadequate insulin production and/or insulin action.[2] Of an estimated 13% of the US population aged 20 years or older that has diabetes, only 60% of cases have been diagnosed.[3] Overall, it is estimated that 8% of the entire population of the United States has diabetes.[2] Diabetes may result in significant morbidity, leading to conditions such as blindness, cardiovascular disease, kidney disease, and premature death.[2] Statistics from 2007 estimated the total cost of diabetes in the United States to exceed $170 billion dollars. An estimated $116 billion dollars were spent on direct medical costs and $58 billion dollars were spent on indirect medical costs (eg, disability).[2]
Diabetes is often successfully managed with lifestyle modifications and drug therapy. Insulin supplementation, required by one fourth of diabetic patients,[2] has been shown to improve patient outcomes by decreasing blood glucose and, potentially, via vasodilatory and anti-inflammatory effects.[4]
Due to complex individualized dosing and administration regimens, insulin is not a “one-size-fits-all” medication. Medication errors associated with insulin use have the potential to cause patient harm and are responsible for 80% of inpatient errors caused by glucose-lowering agents[5] and 10% of all harmful drug errors.[6] The Institute for Safe Medication Practices (ISMP) placed insulin, subcutaneous and intravenous (IV), on a list of “High-alert Medications” due to its potential to cause serious patient harm if given in error.[7,8]
This program will provide clinicians with an understanding of the causes of and risks for insulin errors and tools to prevent such errors.