Remove vials from cartons
From the May 8, 2008 issue
During ISMP medication safety system consultations, we regularly visit patient care units in acute care facilities. One safety concern that we occasionally encounter is the practice of storing insulin vials inside open cartons (that came along with the product when dispensed by pharmacy). We recommend that these external packaging cartons be discarded prior to dispensing or at the time of receipt on the nursing unit. This should be done whether insulin vials are labeled for specific patients or placed into floor stock. Otherwise, vials may be returned accidentally to a mismatched carton after use, a condition that sets the stage for a serious insulin mix-up if the product is identified by the outer carton instead of the label. To prevent patients from getting the wrong insulin product from mismatched vials and cartons, do not dispense or store insulin vials in cartons on patient care units.