Acute coronary syndrome
Mrs A, a patient with type I diabetes, was admitted to hospital with acute coronary syndrome. Prior to admission, she was receiving Novomix 30® 8 units in the morning and 20 units in the evening. On admission to the cardiology ward, the FY2 doctor prescribed Novomix 30® 8u in the morning.
What could be the potential consequence of this?
What type of active failure is this?
How could this have been prevented?
Case study
The nurse could have interpreted the dose as 80 units which would result in severe hypoglycaemia.
This is violation failure.
This could have been prevented by not abbreviating units to u
Link to GMC guidance Good Practice in prescribing and managing medicines and devices
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