Year: 2025
Type: article
Abstract: I 1 O ver the years, the Patient Safety Authority (PSA) has highlighted numerous errors involving insulin.[1][2][3][4][5] Recently, PSA has received several reports via the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing errors with U-500 insulin that led to patients receiving either five times less or five times more insulin than intended.Humulin R U-500, a type of insulin that is five times more concentrated than U-100 insulin, is used to manage blood glucose levels in individuals with diabetes mellitus requiring more than 200 units of insulin per day.6,7 As a high-alert medication, 8 U-500 insulin has been associated with dose errors that can lead to life-threatening hypoglycemia or hyperglycemia.6 There are many ways in which wrong dose errors can occur with insulin.The unique measurement system of insulin using "units" instead of the conventional milliliter (e.g., 1 mL=100 units) inherently complicates its dosing.2,3,5 The potential for errors is further amplified by the availability of various formulations, concentrations, and delivery devices.1,2,7,[9][10][11][12][13][14] In the recent PA-PSRS reports, fivefold wrong dose errors with U-500 insulin occurred after the patients' home dose of insulin was incorrectly reconciled during admission to facilities that use 1 mL tuberculin or U-100 syringes to administer U-500 insulin.Presently, the U.S. Food and Drug Administration advises that U-500 insulin should only be administered using specifically designed U-500 syringes.15
Source: Patient Safety
DOI: 10.33940/001c.144287
Author: Myungsun Ro
Language: English
Subfield: Emergency Medical Services
Field: Health Professions
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4415396245