A 33-year-old woman with type I diabetes mellitus
was admitted for symptoms of left flank pain, dysuria, and emesis,
concerning for pyelonephritis. The patient was taking 40 units of
Lantus daily and 10 units of NovoLog with meals and reported good
glycemic control on this regimen. On exam, she was febrile but with
otherwise normal vital signs, and her laboratory studies were
notable for a leukocytosis and glucose of 275. A computed
tomography (CT) study confirmed pyelonephritis but also showed
marked left-sided hydroureter and hydronephrosis. Urology
recommended that the patient be kept NPO overnight in case a
procedure was required the following morning. The patient was
started on ceftriaxone and intravenous fluids while the new intern,
working on his first call night in July at a new hospital, thumbed
through the different insulin order forms.
The intern came from a
hospital system (as a medical student) that relied entirely on
paper orders. This particular hospital used different insulin order
forms depending on whether the patient was insulin-dependent,
eating, or NPO. The confused intern chose the wrong form, causing
the patient to receive insulin in doses that failed to account for
her NPO status. At 6:00 the following morning, the intern was
called when the patient became unresponsive with a glucose level of
32. The patient responded quickly to treatment with D50 and had a
full recovery once the error in insulin order forms was discovered
around the hypoglycemic event.
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