The Pharmaceutical Journal Vol 267 No 7160 p191-193
11 August 2001

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Drug administration

Insulin dose interpretation errors

From Ms M. E. Miles, MRPharmS and Ms S. J. Sweeney, MRPharmS

Within the past six months an identical drug error has occurred in two nursing homes in our areas. The incidents involved incorrect doses of insulin being administered. In both cases units had been abbreviated to IU and the evening dose for both patients had appeared as 6IU on the label and on the medicines administration record. On both occasions the dose had been interpreted by the nurse on duty as 61 units. Both patients recovered but only after admission to hospital.

The British National Formulary states that units should not be abbreviated and if this advice had been followed these errors would not have occurred.

Mair Miles
Pharmaceutical Inspecting Officer,
Leeds Health Authority

Sandra Sweeney
Pharmaceutical Inspecting Officer,
North Yorkshire Health Authority

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