Yikes. Ever switched your insulins around?

I've been living in mild fear of this for over a year and I finally did it: I calculated my Novolog bolus, picked up the wrong pen and...injected Lantus instead.


The good news is that I just this morning decided to switch Lantus to two shots per day, so I'm still under my daily total for Lantus (I can just subtract the extra from my 7 p.m. shot this evening and I'll be OK.)

But seriously, how did I do this? I broke the cardinal rule that my first CDE taught me when I had my first insulin injection lesson: "Before you start, calm down, focus, pay attention to what you're doing. Turn off any distractions and breathe for a second before you start."

I guess "Injecting While Distracted" can be just as dangerous as "Driving While Distracted".

Sigh...I guess "Injecting While Hair On Fire" is out, too? Yep.

I was really fearful of doing this with my son when he was on MDI, so I used a pen for his humalog and a vial and syringe for his lantus. In my mind, that minimized the likelihood I would accidentally switch them. Glad your situation turned out all right. Be careful!

When I was on MDI, Jean, I kept my Lantus and my Apidra pens in separate places (one in the butter compartment, one on the bottom shelf). Still, I came close to doing it once, but caught it. I guess it's better that you took Lantus instead of your Novolog than the other way around, and since you were switching, it worked out ok.

Don't beat up on yourself, it's something a lot of people have done or fear doing!

One thing I like about my pump is that I only use one kind of insulin, but I think you said you couldn't get (or didn't want) a pump.

Thanks, Zoe. Yeah, a pump isn't in the cards for me right now: my stupid HMO won't prescribe or cover it and I'm allergic to pretty much every medical adhesive. I haven't really experimented with trying the different adhesive options out there because the doctors at my HMO told me that they don't even know how to manage them (even if I paid cash for it) because they don't use them with any of their patients. Did I mention lately that my HMO makes me crazy?

Actually I just see a PCP who doesn't know anything about a pump; I just manage it myself. And I haven't had any need for an adhesive, my sets stick fine - though I guess the set itself has some kind of adhesive. But I know it's harder for a Type 2 to get a pump and that just doesn't seem right!

Almost did this a couple of times. I inject while talking on the phone, doing other things--bad move. Once, I thought I had taken Apidra instead of evening Levemir, which would have killed me. Which was it Apidra or Levemir? Heart in my throat, fingers ready to dial 911, I calculated how much glucose was needed to stave off imminent death & began chowing glucose. Had to raise BG to 325 to counteract the possible Apidra dose. Ate so much glucose, including that nasty gel, I was about to throw up. Constant testing, of course. Watched BG climb & climb ever higher. Hmmm, guess I took Levemir after all. Spent the rest of the night, getting zero sleep, taming the self-induced 350. Learned lesson #1 that night--pay attention. I look at the vial twice now before I put the syringe in.

I kept my Lantus and Humalog on separate floors! The Lantus was on the third floor in my bedroom and the Humalog was in a corner off the dining room.

I only have a one-bedroom apartment. I don't have much room to work with!

I guess I could keep the Lantus in the kitchen instead of on my desk. I'd have to stand up to go inject in the other room. That should be enough to set off mental alarm bells if I'm on the wrong track, eh?

Having the two pens side-by-side on my desk was probably asking for trouble, even though one is gray and lavender and the other is navy and orange.

Be right back...

OK, the Lantus is now sitting upright in a glass on my kitchen table. Let's see how that goes. I never eat/bolus in there (too cold!!!)

Oh, Gerri, having gastroparesis in the mix must make it doubly hard -- I guess you couldn't test and wait and count on the glucose being absorbed quickly once you saw your blood glucose dropping, eh? You'd have to stay ahead of it. Do you have a glucagon shot around for emergencies?

Yep Been there, Done that.

Never had a problem the decades I was on NPH & regular, cloudy and clear, plus I mixed my shot, always the same way.

However, when I was moved to MDI on split-basal/bolus routine, the Lantus and Humalog could not be mixed. I started MDI using vials & syringes for both. One evening I was out of town and took Humalog instead of half-days worth of Lantus. I realized what I had done when I went to place the syringe back on the night-stand. I noticed the purple cap and realized what I had done. Thank god I knew my ratios etc and was able to reverse the process. I took an index card and noted what I took and ate, when etc. I also called a friend that lived across town to call me on my cell in two hours with instructions to call 911 if I did not answer.

MY BGs ran into the 200s but that was far less dangerous than going severely hypo.

When I had my next doc appointment upon return I asked to try a pen fr Humalog to AVOID making that mistake again. I have continued this practice to Ever since. I LOVE my Humalog pen, its so much easier and convenient, but I have no plans to switch.

Gomer :)

Wasn't a fun night. I could have waited to see if I had actually taken the wrong insulin, but I was terrified I'd drop too quickly to fix it. I had glucagon when that happened. Thank heavens I didn't use it! I forget to get the Rx refilled. What I have now has expired.

I've never done this, but for the life of me I can't work out why. I've done every other thing that repetitive behavior mandates, including not remembering *at all* what I've injected myself with 5 seconds earlier (how could I, what reason do I have to remember what I've done almost 15,000 times before?)

It's weird, though, how our short term memory works. I've always known that something bad just happened.

I wouldn't worry about injecting while my hair was on fire though; why would I get that wrong?

The problem is, injecting when TODAY is just like EVERY OTHER day for the last 40 years.

Well, maybe slightly more helpful, I think it never happened to me because I injected the Lantus morning and evening in non-stressful situations where there were always two pens; so my mind automatically made the right choice. I never carried the Lantus around during the day (actually, for the last few years, my wife always carries the stuff, that's a double check).

John Bowler jbowler@acm.org

Good plan. I'd screw things up frequently with pens side by side.


You should remove your email address from your signature line for your protection, especially with your first & last name included. Programs out there to capture addresses, steal identity & load you with Spam.

Oh yeah, I did it bad one time. It was just a month or so after diagnoses too, so I hadn’t really learned the ropes. I took 7 units of novolog but didn’t realize until I woke up half dead at 32. Not sure how I managed to crash into the kitchen at 3 am and wolf down everything in sight. It took about an hour to get my blood sugar stable in the 90’s. Terrible, long, lonely and scary night. I would always rather err on taking levemir instead of novolog because it would only add 1-3 units to my daily dose, as that is how much novolog I generally take at any given time. I keep both my indulins in the same pouch but now I have a pen and a vial.

tudiabetes.org actually removes email addresses enclosed in < and > from messages, I've been trying to bypass this for a while. I only discovered today how to do it.

Believe me, my email address is well known to spammers.

John Bowler jbowler@acm.org

We've had members write about their addresses being lifted. If I can see your address without < >, so can anyone lurking the site & a program searhing "@". Ok, that you don't mind. Just wanted to let you know.

I guess we feel differently.

It only takes two steps to find my name, address and telephone number.

It's a thirty year old computer systems maxim that there is no security in obscurity.

To avoid the ridiculous sitution where it is much easier for my enemies to find out who I am than it is for my friends I attempt to ensure that everyone can find out who I am.

John Bowler jbowler@acm.org

Ewwww Frankie, that's terrifying. I'm glad that you pulled through and are here to commiserate about it now with us. Oh, the warrior tales of diabetes...!!!

That's the thing, isn't it, John: the repetitiveness. I have the same problem with my Synthroid. Day after day after day of taking the same little yellow pill when first stumbling awake (I have to take it on an empty stomach and then wait one hour to eat anything.) Even having a special little pill-minder JUST for the Synthroid doesn't help all that much. Did I take it? Do I just think I took it, but that was a thousand yesterdays, not today? I don't dare risk it with my insulin, so I keep a half-page, spiral-bound log-book and write down everything in it: times, BG readings, carbs eaten, calculations, insulin injected. The very idea of "flying" insulin without my little notebook makes me feel light-headed. So what did I do today? Today I carefully calculated, jotted everything down, and...injected from the wrong pen. More proof of my utterly human fallibility.