Prescriber Update Articles

Medication error - confusion over Humalog insulins

Website: December 2010
Prescriber Update 2010; 31(4):33

Medication errors involving Humalog insulin products continue to occur in New Zealand hospitals.

Three Humalog products are currently available and funded in New Zealand: Humalog, Humalog Mix 25, and Humalog Mix 50. Errors continue to occur during the prescribing, dispensing and administration of these products.

There is potential for harm if a patient receives the wrong Humalog product, for example, the rapid acting Humalog when a combination rapid/ intermediate acting Humalog Mix product is intended.

The following actions are recommended to prevent these errors occurring:

• Prescribe insulin using the full brand name and specify units in full.
• Highlight this potential for error to other healthcare professionals.
• Highlight the potential for error to patients prescribed Humalog or Humalog Mix.
• When using electronic prescribing or dispensing systems double check that the correct item from the drop-down menu has been chosen.
• Confirm with the patient (or carer) that the correct insulin is being prescribed, dispensed or administered.

The manufacturer of Humalog products has made changes to the product labels to help better distinguish between the different products. These changes followed similar issues experienced in Europe.