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Spotted Again: Insulin/TB Syringe Confusion
PA PSRS Patient Saf Advis 2005 Jun;2(2):18.    
 

In an October 28, 2004, Supplementary Advisory (Vol. 1, Sup. 1), we reported mix-ups between insulin and tuberculin (TB) syringes leading to insulin overdoses. PA-PSRS has received a recent report in which 50 units of Humalog was mistakenly administered instead of the ordered dose of 5 units because a TB syringe was used by mistake. As a result, the patient’s blood glucose level to dropped to 50 mg/dL.

Strategies that may help limit the potential for this confusion include: storing insulin syringes separately from all other syringes and evaluating whether TB syringes are needed in patient care areas. See the December 2004 Advisory (Vol. 1, No. 4) for strategies from other Pennsylvania facilities.

 
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Spotted Again: Insulin/TB Syringe Confusion



THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS  
PSA LOGO The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .      
ECRI LOGO ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.      

ISMP Logo The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.      
 
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