A New Challenge for Safe Ordering of U-500 Insulin: Electronic Medicine Reconciliation

Abstract

T he transitioning of insulin orders for patients treated with U-500 regular human insulin from outpatient to inpatient settings and then back to the outpatient setting after hospital care is a safety challenge. Many hospitals follow the Institute of Safe Medical Practices (ISMP) guidelines for use of U-500 insulin.1 ISMP advises that the actual units and volume of insulin be used when ordering insulin. For example, when a patient is administered 0.15 ml of U-500 insulin, or 15 units on a U-100 syringe, ISMP advises that the actual number of units, “60 units of U-500 regular human insulin,” be part of the order. However, a neophyte to U-500 insulin could misinterpret the order for 60 units and draw up 60 units on a U-100 syringe, or 0.6 ml of U-500 insulin. This would result in an overdose of 300 actual units of insulin. Many institutions require that all doses of U-500 insulin be drawn up by a pharmacist to prevent this type of error. This following case demonstrates a new potential source of error associated with the use of electronic medicine reconciliation at discharge. J.J., a …