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Publication Type: Risk Alert
Single or Multiple Incident: Multiple
Date: 7/1/2020 12:00:00 AM
Country: Hong Kong

This alert describes two medication safety incidents related to administration of insulin in the perioperative treatment of diabetes mellitus (DM) patients. In the first case a patient with hyperkalemia was prescribed Insulin Neutral Human (Actrapid HM)® Injection 100 units/mL, 50 units in 49.5 mL Dextrose 50% over 30 minutes as a continuous infusion for one dose. The intended dose of Actrapid® was 8 – 10 units. A resulting drop in blood sugar and hypoglycemia occurred. In the second case, a patient with elevated blood sugar was prescribed Insulin Neutral Human (Actrapid HM)® Injection 100 units/mL, 50 units to 50 mL Gelofusine® to be given by intermittent IV infusion at 3 mL per minute. A resulting drop in blood sugar and hypoglycemia occurred. The default infusion rate in the IMPOE for an intermittent infusion is the dose given “per minute”. The intended rate was 3 mL per hour by continuous infusion. Recommendations to prevent similar incidents are provided.

Additional Details

Medication/Gas/Fluid:
insulin, Insulin Neutral Human (Actrapid HM)®, dextrose 50%, Gelofusine® (succinylated gelatine, modified fluid gelatine), plasma volume expander
Medication/IV List:
insulin, subcutaneous and IV


Insulin Infusion Safety Tips (I) Different concentration & different infusion rate for different indications