September 2005, Volume 35 Number 9 , p 18 - 20
COHEN, MICHAEL R. RPh, MS, ScD
President of the Institute for Safe Medication Practices
When a patient with diabetes who was taking the insulin adjunct pramlintide acetate (Symlin) was admitted to a hospital for a different problem, the endocrinologist ordered “Symlin 20 units.” The patient had taken her vial from home for use in the hospital without the package insert.
Unfamiliar with the new drug, the pharmacist consulted a drug reference. Learning that doses are expressed in micrograms, he concluded that the endocrinologist must have meant to order 20 mcg. After the pharmacist and the nurse discussed the issue, the nurse entered the dose as 20 mcg in the patient's medication administration record (MAR).
Symlin is supplied in 5 ml vials at a concentration of 0.6 mg/ml. The manufacturer recommends using a U-100 insulin syringe to measure doses, so a “20 unit” dose equals 120 mcg. Because of the erroneous MAR entry, the patient received ...