1. Section Editor(s): Cohen, Michael R. RPh, MS, ScD

Article Content

Computerized prescriber order entry and electronic medication administration records (MARs) can simplify healthcare and make it safer. But sometimes technology itself can create sources of errors that aren't discovered until a problem arises. A hospital that prints computer-generated MARs for distribution to patient-care units discovered this the hard way.


NovoLog Mix 70/30 (insulin aspart protamine, insulin aspart), 10 units by subcutaneous injection before breakfast, was prescribed for a patient with diabetes. The hospital used insulin pens to improve the safety and efficacy of insulin delivery, so the order was entered into the pharmacy computer as "insulin aspart prot:insulin aspart (NovoLog FlexPen 70/30) 10 unit SUBCUT ACBRKF." Because the computerized MAR allowed a limited number of characters per field, this order was truncated and appeared as "NovoLog FlexPen 70."


The patient also was receiving regular insulin via a NovoLog FlexPen for sliding scale coverage, so the nurse administered 70 units. The patient became hypoglycemic and needed 50% dextrose and close monitoring, but didn't suffer any lasting harm.


The error wasn't noticed until 2 days later, when another nurse misinterpreted the drug name on a different patient's MAR and a more experienced nurse questioned the high dosage. The hospital has since changed its MAR profile for the NovoLog Mix 70/30 FlexPen and is working with the computer system vendor to prevent data truncation on MARs and pharmacy labels.


Providing the full brand name (including the word "mix") can help distinguish NovoLog Mix 70/30 from NovoLog. If you have computerized MARs, check with your pharmacy to learn if this is a problem.