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Increase in insulin mix-ups initiates computer system update
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Reported errors made in the selection of U-100 and U-500 insulin — dangerous mistakes that could result in hypoglycemia or hyperglycemia — have increased, according to an FDA Patient Safety News report.
The Institute for Safe Medication Practices proposes the errors may be a result of the current computer system that lists the products one line apart; small computer monitors that do not accurately display the entire product name; and the unexpected availability of U-500, a less-common concentration that may cause prescribers to pay less attention when choosing a product.
As a result of the reported mix-ups, drug information system suppliers have decided to add the word “concentrated” to their screen selections both before and after “U-500.”
The ISMP recommends the following until these updates appear in computer systems:
- Consider differentiating between U-500 and other insulin products if U-500 is not commonly used in your facility. Doing this will keep U-500 from appearing on the same screen as other insulin products.
- Add a hard stop to orders for U-500 so that prescribers and pharmacists must verify U-500 for the patient.
- If pharmacies do not have patients that use U-500, consider not stocking it to avoid mix-ups.
Due to a higher prevalence of obesity, the use of insulin pumps and strict glucose control practices in hospitalized patients, the ISMP proposes the use of U-500 insulin may be increasing.