Dose Confusion When Switching between Insulin Delivery Devices
This bulletin follows a case reported to ISMP Canada of a dosing error with a high-concentration insulin product. The case involves the incorrect dose being administered following a switch from a U-500 multi-dose vial to a U-500 insulin pen. The patient incorrectly reported their actual dose because they were using a U-100 syringe to draw up the dose from the U-500 vial and reported their dose in units only. Contributing factors were that the delivery device was not specified to the prescriber, and that the delivery device did not accurately reflect the true dose administered.
- Communication Gap
- Special Access Program (SAP)
- Communication about Special Access Programme Medications
- How to Safely Transfer Your Prescriptions