Observation of Medication Errors Made by Diabetic Patients in the Home

Abstract

Observations for accuracy in carrying out prescribed medication regimens were made at home on two groups of diabetic patients. The first group included sixty patients (all taking insulin and cared for in two university clinics), and the second 102 patients (fifty-five taking insulin and fortyseven taking oral hypoglycemic agents) cared for in two university clinics, a voluntary hospital clinic, and twentytwo different private practices. Fifty-eight per cent of 115 patients taking insulin made dosage errors. “Potentially serious” errors, i.e., those in which the measured dose differed from the prescribed dosage by 15 per cent or more, occurred in 35 per cent. In the first group, seven of thirty-four patients (21 per cent) using the U40-U80 “convertible” syringe measured either half or twice the prescribed dose through use of the wrong scale. Rates of error were similar in clinic and in private patients. The frequency of insulin errors increased with duration of known diabetes. Among forty-seven patients taking oral drugs, 23 per cent made “potentially serious” errors, and 26 per cent reported missing one dose or more per month. The findings indicate the need for more extensive knowledge of what the diabetic patient does at home, for seeking the reasons for his behavior, and for finding ways to achieve sustained-improved performance.