OBSERVATION OF MEDICATION ERRORS MADE BY DIABETIC PATIENTS IN HOME

Observations for accuracy in carrying out prescribed medication regimens were made at home on 2 groups of diabetic patients. The 1st group included 60 patients (all taking insulin and cared for in 2 university clinics), and the 2nd 102 patients (55 taking insulin and 47 taking oral hypoglycemic agents) cared for in 2 university clinics, a voluntary hospital clinic, and 22 different private practices. Fifty-eight per cent of 115 patients taking insulin made dosage errors. Potentially serious errors, (those in which the measured dose differed from the prescribed dosage by 15% or more) occurred in 35%. In the 1st group, 7 of 34 patients (21%) 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 47 patients taking oral drugs, 23% made potentially serious errors, and 26% reported missing 1 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.