Wednesday , October 18 2017
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Diabetes Disaster Averted #10: Look-Alike Syringe Problem

A nurse mistook a standard tuberculin syringe for an insulin syringe and gave a patient 50 units of insulin instead of the prescribed 5 units….

Sounds unlikely, doesn’t it? Well, the hospital had recently switched from Becton Dickinson syringes to VanishPoint syringes (from Retractable Technologies) before all nurses could be alerted. The VanishPoint tuberculin syringe is packaged in a white wrapper with black and orange print, and the syringe has an orange plunger tip (see photo). Most nurses associate the color orange with insulin syringes. In this case, the new tuberculin and insulin syringes were accidentally mixed together in a drawer. The stocking error was caused by the similarities between the outer boxes that hold the insulin syringes and tuberculin syringes. When the nurse selected the syringe from its usual storage area, she saw the orange color on the plunger tip of the tuberculin syringe and thought it was an insulin syringe. To make matters worse, naked decimal points (e.g., .1, .2) are used to represent the gradations on the syringe (and 1.0 is used to represent 1 mL). Since the nurse thought she was using an insulin syringe, she failed to notice the decimal point and thought the “.5″ mL marker represented 5 units. While mix-ups between a 3 mL syringe and an insulin syringe are less likely, the 3 mL VanishPoint syringes with a 25 gauge needle use an orange color code on the syringe cap and wrapper.

Thankfully insulin takes a while to go to work and one of the nurse’s colleagues noticed the odd syringe and they were able to monitor the patient and use D50 ampules to prevent hypoglycemia.

Lesson learned: Evaluate whether tuberculin syringes are needed in patient care units. Except in pediatric units, the syringes often are used primarily for skin tests or small subcutaneous doses that could be dispensed in a syringe from the pharmacy. Tuberculin syringes also may be used inappropriately as an oral syringe. It’s also helpful to store insulin syringes separately from all other syringes, perhaps near the refrigerator where insulin is stored.




Report Medication Errors to ISMP:

Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.



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