AstroNutrition Health & Fitness Blog

Here’s a paper in the The British Journal of Diabetes & Vascular Disease I’ve just published with a colleague about prescribing errors in diabetes that may be of interest to some readers.

Prescribing errors in diabetes have the potential to cause serious adverse effects. Antidiabetic agents are a significant cause of admission to hospital. Prescribing errors can be caused by poor handwriting, failure to communicate clearly, and by the use of inappropriate abbreviations. Serious errors involving insulin have been reported in the UK media. While education and training may reduce the number of errors, experience shows that errors will continue to occur without changes to systems. Br J Diabetes Vasc Dis 2009;9:84—88

Here is a list of UK newspaper reports of errors related to the use of insulin in hospitals since 2000:

2001 Blood glucose reading misinterpreted, and failure to monitor insulin pump. Fatal.

2001 Junior doctor ignorant of insulin syringe use; ten times overdose; attributed to lack of training. Fatal.

2002 70 units to be administered to child by nurse, instead of 7 units; error spotted before administration by parent No harm.

2002 Misheard advice over phone; led to 50 units being prescribed instead of 15 units. Patient died, but coroner did not attribute death to error.

2003 Junior doctor administered 50 units instead of 5 units. Fatal.

2003 Overdose of insulin; no details available. Coroner recorded verdict of death by natural causes, but patient did not recover consciousness following error.

2004 Poor handwriting in prescribing records led to 40 units being given instead of 4 units. Fatal.

2005 Junior doctor used wrong syringe, believing 1 unit of insulin in 1ml; 100 times overdose; attributed to lack of training. Fatal.