incorrect dosage

jevan28

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hi my dad is a diabetic and has always self prescribed....after being in hospital he was discharged still too poorly to give himself insulin my mum used the dischagre prescription to give him his insulin over a couple of days he was admitted to hospital twice and had really low sugar we since found out the dosage given on the prescription from the hopsital was incrrect the hospital said the computer malfunctioned i don't know if this can happen but surely the prescription should have been discussed with my mum before discharge? :D
 

hanadr

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Any diabetic on isulin, should have their treatment explained clearly and simply. Ideally they should also attend a training course. (Not in my area, they don't run them)
If someone is newly diagnosed, they,or their carer, may not be in a fit state to take in all the information.They need time to digest it and should be monitored during the soaking up time.Computers are only as good as their operators. GIGO (Garbage In~GARbage OUT) Don't settle for it. Chase them up ASAP. You are risking serious consequenses and the medics who are advising would be to blame.
Sometimes I wish our medics were as scared of being sued as their US counterparts.
 

jopar

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Jacvan28

Where was your mum getting the doseage infromation from?

I ask this because of the nature of insulin, dose information isn't writtien on the prescription, nor only the priscription lable of the box, it will only ever say 'use as directed'

So I would be surprised that this could be blamed on a computer malfunction problems...
 

jevan28

Member
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it was given on the discharge sheet from the hospital it read :

INSULIN GLARINE (LANTUS 3ML)
100 UNITS/ML (3ML)

INJECT 0.1 UNIT DOSE TWICE A DAY
 

lilibet

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0.1 Units of Lantus? I dont use it but I didnt think it could be dosed that low (only heard of 0.5 measurements and even then its hard to get a hold of it -usually for kids)

If that was the dose Im surprised your dad would have been in hospital with low bg cause it doesnt make any sense to me at all.

Agree with hana's point though - fault lies with med profs, who should be checking the discharge sheet before discharge. I mean, were not talking about a spelling mistake here, its insulin - overdoses are dangerous, underdoses are dangerous.

I think that inpatient diagnosis/treatment is scandalous. I intended to write to my PCT about my experience but then it just filtered off, what with the diabetes an all. My GP actually said I should complain. Oh If i knew then what I know now...............

So, give them a boot up the **** and dont let them fob your poor dad off.

L
 

jopar

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This gets stranger indeed

The first two bits, is the lantus, saying that it's 3ml, as lantus and glarine are the same, the 3ml is the cartridge size being used (not a vile which is 10ml)

The next bit is basically the strength of the insulin all insulin that is supplied in this country is standarised stength, most common around the world, but many years ago insulin would be issued in different strengths.. There is 500u/ml, put this is only available in Amercia, and can only be imported into this country by a consultant for a named patient...

And basically the dosage that they've got marked up, because with pen or syringe the mimium that can be inject (that is if you can get hold of a cable pen or syringe) is 0.5 unit... The only piece of equipment that I know that could deliver such a small amount of insulin is a insulin pump, and this is used with quick acting insulin only... Not lantus or other slow acting insulins..

I ponder what amount was injected, as it's impossible to inject such a small amount in the first place, and if you could inject such a small amount then it would very unlikely cause your dads hypo (low sugar levels) I think you need to ask them if they can remember how much they might have injected and when.. Lantus is a timed injection, it is normally injected once a day, at a set time, i.e every night at 8pm, if it's given twice a day then you would inject at 8am and then at 8pm...

I would suggest if you haven't done so, is make a offical complaint... But first get hold of the diabetic clinic or dad consultant team, and demand that his injections, dose to be use and the ins and out's is sorted now, so that not only your dad but your mum knows what to do and what to expect...

It's seems that a serious error has happened here, by discharging your dad from hospital, with out ensuring he or his carer (mum) has been given the correct information for the treatment of his medication regime...
 

jevan28

Member
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6
the hospital have said that it was an error on the computers behalf and that it wasn't incorrect as well as this he was discharged again after a fall and four days later he was diagnosed with some bobe infection that is prone to patients with diabetes and a fall and they've now said they have no record of the fall.
 
C

catherinecherub

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There should be a P.A.L.S. (Patient Liaison Advice Service) at the Hospital. They will give you good advice about how to take this further and it is free. They enquire on your behalf and are excellent. Someone is telling porkies and you need an explanation of what has happened regarding the insulin and the fall.
Hope this helps,
Catherine.
 

jevan28

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6
cheers Catherine. i appreciate the advise. i've got a copy of the dischagre sheet, but after swnding two letters they keep referring to a computer malfunction.
 

hanadr

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Hi Jevan
If it's a computer malfunction, ask to speak to the computer department.
It's porkies!
that's not the kind of thing computers do when they malfunction. They tend to stop working a all or freeze or something, not spew out incorrect information.
In any case, you need the correct information.
AfterPALS, try Citizen's Advice.

If you get no help by conventional means,Try taking your Dad with the discharge sheet to A&E.
It's not the right way to treat the emergency services, but it could easily become an emergency.
 

jevan28

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cheers, it did turn out to be an emergency over three days of not having the correct insulin he was admitted into hospital and had an emergency doctor!
 

hanadr

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Lets hope the A&E people got it right.
Now ask to speak to the complaints department. they must have one
 

jopar

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Having some experience of computerised medication system and care plans, you would be surprised to what ‘malfunction’ these can have… Sometimes bugs in the system take a long time to come to light…

Javen

If you complain request that you are informed on what happened with the computer to cause it to malfunction, and that you also want to know what procedures they have put into place to ensure that this doesn’t happen again…
 

Trinkwasser

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Due to a computer malfunction one of my colleagues ordered some gaskets at £49 each

They were actually, as the supplier helpfully pointed out, 49 PENCE each (someone miskeyed the decimal point) not truly a computer malfunction but a human malfunction which the computer took literally

One of our customers once ordered 100 *rolls* of pipe when he actually wanted 1 roll of 100m

In the medical field there should be enough checks and balances that such errors are caught