An Insulin Incident...

The nurse on the ward was not familiar with the use of insulin and, in fact, was not familiar with treating diabetic patients. She read the JMO’s order as 200 Units of insulin and proceeded to administer this dose to the patient. Soon after, the patient became clammy and lost consciousness. The diagnosis of hypoglycaemia was promptly made and appropriate treatment instituted. Fortunately, the patient did not suffer any long term adverse sequelae of the insulin overdose. 

This case underscores the importance of avoiding the use of the abbreviation ‘U’ for Units of medication. When charting insulin or heparin, the word ‘Unit’ should be always be used (rather than “U”) in order to prevent errors involving an overdose of these medications.