Patient Errors in Use of Injectable Anti-Diabetic Medications: A Need for Improved Clinic-Based Education

Objectives This case series was designed to educate and inform healthcare professionals on the importance of providing adequate education on injectable anti-diabetic agents and highlighting common medication errors related to diabetes care seen in an ambulatory practice. The discussion following case descriptions will attempt to characterize patients who may be at high risk for these errors and identify ways to reduce the potential for error. Case Summary Within a Diabetes Care Clinic, four cases were identified in which the patient experienced escalation of insulin or other injectable anti-glycemic medication doses with no improvement in glycemic control. Two of the cases involved failure to remove an inner needle cap due to a poor understanding of pen logistics. One case was attributed to switching formulations without providing proper education for an adult patient with a learning impairment, and the other case was attributed to suboptimal absorption of insulin doses from lipohypertrophy. Three of the four cases resulted in multiple instances of hypoglycemia, and all four cases exhibited markedly improved glycemic control once the injection error was corrected. The clinic pharmacist provided an essential role in identifying and correcting administration errors within an interdisciplinary team. Practice Implications Based on the observations from the four cases, clinicians should be prompted to review anti-diabetic medication injection techniques prior to initiation and periodically thereafter with their patients. Factors that should prompt further education include low health literacy, language barrier, initiation of medication by another provider, switch of medication product or formulation, obvious discrepancies between refill history and patient's self-reported adherence, observed lipodystrophy, and escalating doses without any improvement in glycemic control. A referral to the clinic pharmacist should be considered to provide more detailed education for these patients.