| Contents | Previous | Next |
A brittle diabetic patient being treated for ketoacidosis was transferred from the intensive care unit to a medical/surgical floor. A new graduate nurse checked the patient's orders: He was to receive 9 units of NPH insulin at 4:30 p.m.
Since the unit was temporarily out of insulin syringes, the nurse decided to use a l-ml tuberculin syringe instead. This syringe was graded in tenths of a milliliter, and since U-IOO insulin was being used, she thought she could determine the correct dose. She drew up the insulin to the 0.9 ml mark and administered the injection.
The patient ate poorly at dinnertime. Around 8 p.m., the nurse noted he was groggy and sweaty. She called a doctor, who immediately ordered a blood glucose level measurement-it showed extreme hypoglycemia. He injected 100 ml of 50% dextrose solution, and the patient gradually recovered. But not until the next day did the nurse realize that 0.9 ml of U-1OO insulin drawn up in the tuberculin syringe equaled ninety units, not nine.
This nurse learned the hard way two cardinal rules for administering insulin: (1) Use only an insulin syringe to draw up and administer insulin, and (2) have another nurse double-check the dose you've drawn up. If the hospital pharmacist has prepared a unit-dose syringe of insulin, double-check his work.