A number of mix-ups between two dosages of insulin have been reported recently, the FDA said in the September 2008 issue of its “Patient Safety News.”
The mix-ups—which can result in dangerous hyperglycemia or hypoglycemia—occurred when providers accidentally selected insulin U-500 from a computer screen instead of U-100.
Major suppliers of drug information systems have agreed to add the word “concentrated” following the drug name for U-500.
In the meantime, the Institute for Safe Medication Practices recommends:
- Listing U-500 separately from other types of insulin if it is not commonly used
- Hard stopping all orders for U-500
- Not stocking U-500 if no patients use it