The insulin that does not match the chart
It is 07:30. You are checking the medication chart for Mr Nguyen, 54, type 1 diabetes, before the morning medication round. The chart orders 18 units of a long-acting insulin subcutaneously at 08:00, and a sliding-scale short-acting insulin with meals. His blood glucose at 07:00 was 4.1 mmol/L and he is alert but says he feels 'a bit shaky'. He has an IV cannula, is nil by mouth for a planned procedure at 10:00, and his breakfast has been withheld. The EN has already drawn up the long-acting insulin and is about to administer it.
1. What checks should have occurred before administration, and what has gone wrong?
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The EN has skipped the rights of medication administration and the clinical context.
Required checks:
- Right patient - identity band and consent.
- Right drug and dose - against the original order, not a transcription.
- Right route and time - subcutaneous, 08:00.
- Right documentation - the chart and the administration record.
- Right reason and clinical appropriateness - this is the step that failed.
What has gone wrong:
- Hypoglycaemia is being ignored. A glucose of 4.1 mmol/L with shakiness is a warning sign. Giving long-acting insulin now risks a serious hypo, particularly with nil by mouth and no breakfast.
- Nil by mouth changes the plan. The sliding scale is meal-based; with no meal, the short-acting component should not be given, and the long-acting dose needs prescriber review.
- Preparation before assessment. Drawing up before checking the glucose and the fasting status is a process error.
I would stop the EN, thank her for preparing, and explain the concern. I would not administer, and I would treat the low glucose first.
2. Describe your immediate clinical actions and the escalation you would make.
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Immediate actions:
- Stop the insulin from being given.
- Treat the hypoglycaemia per protocol - if she can swallow safely, give fast-acting carbohydrate (e.g. 15–20 g glucose) and recheck in 15 minutes. If she cannot swallow or is drowsy, follow the IV glucose protocol. She is nil by mouth for a procedure, so confirm with the team whether oral glucose is permitted; hypoglycaemia is an immediate threat to safety and takes precedence, but I would document the discussion.
- Recheck blood glucose every 15 minutes until stable, then hourly.
- Notify the prescriber - the long-acting dose and the fasting plan need review; the procedure may need to be delayed.
- Inform the anaesthetist/procedure team of the hypoglycaemia and nil-by-mouth status.
- Complete an incident report and inform the nurse in charge.
Escalation (ISBAR): 'Mr Nguyen, 54, type 1 diabetes, nil by mouth for a 10:00 procedure. Glucose 4.1 and symptomatic. Long-acting insulin is due at 08:00 but I have withheld it pending your review. Please advise on dose, fasting plan, and whether the procedure should proceed.'
Afterwards I would debrief the EN supportively and review the ward's pre-procedure medication checklist.