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Fifty Hospital Employees Given Insulin Instead of Influenza Vaccine

Our Brazilian sister organization, ISMP Brasil, distributed a national alert last week after being notified of an error at a hospital where 50 employees received a dose of insulin instead of influenza vaccine. The person in charge of vaccination of hospital staff confused the multiple-dose vials, which were similar in appearance, and she took the wrong box out of a refrigerator where both insulin and influenza vaccine were stored. She administered the wrong substance to her colleagues and to herself. The administration of vaccines began at 9 a.m., and the error was discovered around 10 a.m., at which time glucose injections were administered. All of the employees who received an insulin injection were hospitalized for observation until later in the evening. Although not mentioned, the erroneous insulin dose was likely 50 units or 0.5 mL, the typical influenza vaccine dose.

The exact same error, administering insulin instead of influenza vaccine, has been reported many times around the world, including several cases in the US. Some cases have been fatal. In 1997, The World Health Organization (WHO) reported an incident in which 21 infants died after receiving insulin instead of diphtheria, pertussis, and tetanus (DPT) vaccine. Errors similar to these mix-ups have also happened with administering influenza vaccine instead of purified protein derivative (PPD) skin tests for tuberculosis, and neuromuscular blockers instead of influenza vaccines, due to nonsegregated storage in emergency department refrigerators.

Keeping influenza vaccine readily available next to other medications can lead to errors. We strongly advise storing vaccines away from other drugs, in a separate refrigerator. The Centers for Disease Control and Prevention (CDC) recommends keeping vaccines in storage units dedicated only to vaccines. These incidents show how important regular, thorough drug storage checks in hospitals and ambulatory care areas are to observe and address potentially hazardous storage conditions. Errors involving look-alike vials can also be prevented by using commercially available prefilled syringes of vaccines.

Here are some other reports of insulin injections given instead of influenza vaccine: