USP Quality Review

No. 58, Issued 03/97

Health Care Practitioner Errors

Analysis of the USP MER Program database reveals additional factors that may precipitate medication errors. The following three factors, in addition to others, may have contributed to the two reported errors described below, which were initiated by health care practitioners:

  • use of different products with similar indications for use

  • use of different products with similar dosing

  • use of different products with identical units of product strength.

The following errors with Humalog were initiated by health care practitioners:

  • A patient mistakenly received Humulin instead of Humalog. The nurse went to the automated medication dispenser at the nursing station, opened the drawer, retrieved Humulin instead of Humalog, and administered it to the patient. Patient outcome is unknown at this time.

  • Hospital staff had received instruction on the appropriate dosing and administration of Humalog. Despite training, some nurses continued to administer Humalog 30 to 45 minutes before meals instead of within 15 minutes of a meal. To ensure that it is administered appropriately in the future, the pharmacy attached to each Humalog vial a bright sticker that states "take with meals."