On April 30, 2016, fifty employees at a Brazilian hospital received a dose of insulin instead of the influenza vaccine.
The vaccine and the insulin were stored in the same refrigerator, and were retrieved by a staff member who confused the two similar-looking vials. The staff member took the wrong box from the refrigerator.
Those who received the incorrect, influenza-portioned injection of insulin were hospitalized. No adverse events have been reported.
Always separate look-alike vials and clearly label. Differentiation is key.
A new regulation effective January 2011, Patient-Centered Labels for Prescription Drug Containers (Title 16 Section 1707.5), includes among other provisions a standardized set of patient instructions expected to cover about 90 percent of prescriptions. While the regulation affects labels on drug containers dispensed to patients, the standardized text can also provide a method for reducing discrepancies on other documents such as discharge instructions and prescription slips.
To assist healthcare professionals in the delivery of optimal patient care, USP establishes standards in the United States Pharmacopeia and the National Formulary (USP–NF) for labeling and physical environments that promote safe medication use (e.g., procurement, prescribing, transcribing, order entry, preparation, dispensing, administration, and monitoring of medications).
