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LETTER TO THE EDITOR |
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Year : 2022 | Volume
: 8
| Issue : 2 | Page : 185 |
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A Possible Cause of Incorrect Dose Administration of Insulin in ICU
Summit Dev Bloria, Jetinder Pal Singh
Department of neurosciences, Shri Mata Vaishno Devi Narayana Hospital, Katra
Date of Submission | 07-Dec-2021 |
Date of Decision | 09-Jan-2022 |
Date of Acceptance | 11-Jul-2022 |
Date of Web Publication | 23-Aug-2022 |
Correspondence Address: Summit Dev Bloria Department of neurosciences, Shri Mata Vaishno Devi Narayana Hospital, Katra
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mamcjms.mamcjms_129_21
How to cite this article: Bloria SD, Singh JP. A Possible Cause of Incorrect Dose Administration of Insulin in ICU. MAMC J Med Sci 2022;8:185 |
Drug errors continue to be common both in operation theaters and in intensive care unit (ICU).[1],[2] We wish to highlight an important cause of administration of incorrect dose of insulin. A diabetic patient admitted as a case of ischemic stroke in our ICU was shifted to Lantus insulin (Biocon Biologics limited, Malkagiri, Telangana) from regular insulin. During the rounds on the next day, it was observed that the nursing staff was administering the Lantus insulin using the same set of syringes [Figure 1] as they were using for regular insulin administration. However, while the regular insulin we used was 40 U/mL, the Lantus insulin used was 100 U/mL [Figure 1]. Hence, the staff was actually administering 2.5 times the advised dose of insulin due to use of incorrect syringe. We believe that the availability of different concentrations of insulin predisposes to administration of incorrect dose of insulin. After this incidence, we sensitized the staff about this error and it was decided that whenever, in future, Lantus insulin was indented from our pharmacy, it would be accompanied with 100 U/mL insulin syringes. | Figure 1 A 40 U/ml insulin syringe when used to administer lantus insulin (100 U/ml) causes wrong dose administration of insulin.
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Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References | |  |
1. | Wilmer A, Louie K, Dodek P, Wong H, Ayas N. Incidence of medication errors and adverse drug events in the ICU: a systematic review. Qual Saf Health Care 2010;19:e7. |
2. | Dhawan I, Tewari A, Sehgal S, Sinha AC. Medication errors in anesthesia: unacceptable or unavoidable? Braz J Anesthesiol 2017;67:184-92. |
[Figure 1]
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