# OAP injected with 10 times amount of insulin



## aymes (Mar 27, 2009)

http://news.bbc.co.uk/1/hi/wales/south_east/7967862.stm


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## Northerner (Mar 27, 2009)

How dreadful! A couple of things spring to mind: how could it be so difficult to use the insulin pens? I was given a two minute tutorial on the use of my two pens - surely they aren't that diffcult? If they are then it's a serious design flaw. Secondly, how could you inject a substance into someone unless you were absolutely sure of the required dose? I made a mistake this morning and dialled up an extra unit. Normally, I'd just squirt it away and start again, but for some reason went ahead. Sure enough, I was 2.9 3 hours later. I can't imagine what I would have been like if I'd over-injected by 28 units! It surprised me that it took six hours to have its consequences, suppose it depends on what type of insulin it was.

It's one thing that has bothered me slightly, that in old age I might be dependent on someone else. I know this is a rare case, but with truly awful consequences.


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## bev (Mar 27, 2009)

It seems that it doesnt matter what the design is - everything is open to the element of 'human error'! What a dreadful thing to have happened - it is a worry that someone can make such a dreadful mistake. Bev


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## Copepod (Mar 27, 2009)

A tragedy, caused by negligence - fortunately a rare type of incident, but rarity is immaterial when it happens to your family.

The report mentions syringe - a syringe that measured in ml, rather than insulin units was used. So, the insulin was probably drawn up from a vial, rather than using a cartridge in a pen device.

The aim with administering medication as a nurse is (in no particular order) right patient, right dose, right time, right medicine, right route - in this case, the wrong dose was administered, because the wrong syringe was used, so the dose could not be measured accurately.

Those with long memories may remember that in the the 1980s, insulin changed from 40 or 80 units per ml to universal 100 units per ml - not all countries changed at the same time, so replacing a loss of insulin overseas was even more complicated.


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## kojack (Mar 27, 2009)

This was a method of terminating life of juveniles by a nurse/nurse assistant in Grantham Lincs some years ago.
She is serving a fairly long time as a guest of HMPS


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## sofaraway (Mar 30, 2009)

I suspect it was lantus in one of those ?opticlick (the white disposable pen), this pen is really difficult to use and has recently been largely replaced by solostar pens When i used this pen I had to get a couple of colleagues to show me how to use it because i found it difficult. So i can understand that she couldn't use it, and decided to draw the insulin from then pen using a syringe. Her mistake was not using an insulin syringe to draw the dose and getting it wrong. 

I think she may get struck off for this. Medication errors happen every single day fortunatly vast majority cause no harm


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## Lizzie (Mar 31, 2009)

I am amazed that the nurse had apparently never used an insulin pen before and had only used a syringe. I would imagine she has never even heard of an insulin pump. I would have expected nurses to be more up to date, pens have been around for years now.


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