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Diabetes Disaster Averted #63: Color Coding Discrepancy

Recently I was on a home visit with a client who was taking Novolin 30/70. She asked me why the insulin band on the cartridges in the fridge was a different color than what was in her pen. She told me the label on the insulin was correct….

When I investigated, I noted that the pharmacist had dispensed the wrong insulin, but had affixed a label for Novolin 30/70 to the box. The client and I discussed always checking the color of the band as well as the inscription on the actual cartridge, rather than trusting what had been dispensed. I called the pharmacy immediately and the client had the correct insulin delivered to her home. The client and I discussed what potentially could have happened and she was very thankful she had trusted her instincts to not take the insulin.

Lesson Learned:

Encourage your patients to always check and then double-check before they take their medications. Because the correct label was put on the wrong insulin, when calling the pharmacy, they would not notice any problem. You need to pay special attention to the color codes and the actual names on the pens, vials or cartridges. And when in doubt, call your doctor, pharmacist or educator.

Janet Wilpstra, RN, CDE, Canada

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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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