Preventing U-100 and U-500 Insulin Mix-Ups: Pass This Information on to Your Doctor & Pharmacist

ISMP says that the major suppliers of drug information systems have agreed to add the word “concentrated” on their selection screens, immediately following the drug name and preceding “U-500,” which should help solve the problem.

Jul 3, 2008

The non-profit Institute for Safe Medication Practices says there has been an increase in reports about mix-ups between prescriptions of insulin U-100 and insulin U-500 (U-500 is a concentrated insulin that is five times stronger than U-100).

The mistakes have occurred when prescribers have accidentally selected U-500 insulin from computer screens instead of U-100. The risk is that these errors can result in dangerous hyperglycemia or hypoglycemia.

ISMP has identified several possible reasons for these errors:

  1. Sometimes dosage forms for the two insulins appear one line apart on the screen, making it easy for a prescriber to select the wrong one.
  2. Depending on the screen size, the prescriber may see only the first few words of the product listing, so the drug concentration may not be visible.
  3. Since the use of U-500 insulin is not common at present, prescribers may just assume that the only regular insulin that’s available is U-100 and not even look for the concentration on the screen. (ISMP suggests that the use of U-500 insulin may be increasing due to the higher prevalence of obesity, the use of insulin pumps, and tight glucose control protocols in hospitalized patients.)
ISMP says that the major suppliers of drug information systems have agreed to add the word “concentrated” on their selection screens, immediately following the drug name and preceding “U-500,” which should help solve the problem. Until these updates appear in prescribers’ systems, here is what ISMP recommends:
  1. If U-500 isn’t commonly used in a facility, the facility should consider listing it differently from other insulins, so it doesn't appear on the same screen as other insulin products.
  2. Consider adding a hard stop to all orders for U-500. This requires prescribers and pharmacists to verify that a patient should be getting the U-500.
  3. Pharmacies should consider not stocking U-500 if they don’t have patients who use it.

Source: The Institute for Safe Medication Practices

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