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
Those who received the incorrect, influenza-portioned injection
of insulin were hospitalized. No adverse events have been
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).