NCPS: Taking Aim at Medication Errors, Question 4

SF: Can you give an example of how the error reporting works?

KT: I have attached a NCPS Alert (in pdf format) from March 2009 on U 500 Insulin. This was the specific incident: "South West VA CMOP received an order for 40 units of U-500 insulin and questioned its validity. The actual dose desired by the physician was 200 units. The physician indicated the 40 units reflected the mark on a U 100 syringe to which the patient was to draw back the plunger"....