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November 28, 2019: Dose Confusion When Switching between Insulin Delivery Devices

Insulin products are supplied predominantly as solutions with a standard concentration of 100 units/mL. However, several high-concentration products (i.e., with concentration above 100 units/mL) are available for patients who require relatively high doses because of significant insulin resistance. These high-concentration products are often provided in product-specific injection delivery devices. Failure to consider the differences among insulin products, including the insulin concentration and the delivery device, can lead to serious dosing errors. ISMP Canada received a report of a dosing error with a high-concentration insulin product, which resulted in an emergency department visit. This bulletin highlights the factors that potentially contributed to the error and recommends a systems approach to reduce the likelihood of recurrence.   Read more ...