USP Quality Review

No. 58, Issued 03/97

Other Medication Errors with Insulin

Forty-four incidents in the MER Program database involve an insulin product. Two incidents resulted in patient deaths; patients' lives were threatened in five incidents; permanent harm to the patients was described in three incidents. According to the reports, the errors occurred because the incorrect syringe was used, because insulin was administered instead of the intended drug (e.g., heparin), or because the inappropriate insulin product was dispensed or administered. The following two incidents have been abstracted from the database:

  • One patient died after receiving a 10-fold overdose of insulin. A pharmacist used a 3-mL syringe (calibrated in minims) rather than an insulin syringe to measure 20 units of insulin. Instead of 20 units, the pharmacist drew up 200 units and added that volume to the patient's total parenteral nutrition. The patient died as a result of the insulin overdose. The preparation was not double-checked by anyone.

  • A two-month-old infant suffered permanent damage after receiving a massive dose of insulin through an intravenous (IV) bag. According to the report, an inexperienced and untrained technician prepared an IV solution containing insulin, which was then administered to the hospitalized infant.