“The Scariest Moment of My Life”

Syringe and vials

During an office visit, a patient with diabetes was switched to a highly concentrated dose of insulin. The Food and Drug Administration requires that a special U-500 syringe be used with this concentration. The physician placed an order in our electronic health record for the high-concentrated insulin and the U-500 syringes. He noted the need for the U-500 syringes on both orders. The physician then electronically sent the orders to the patient’s pharmacy and informed the patient that he would receive a special syringe.

When the patient filled his prescription, the pharmacy provided him with the correct concentration of insulin but – unbeknownst to the patient – gave him the wrong syringe. The syringe the patient received is meant to be used with a much lower concentration of insulin and measures dosing in a different way. Imagine filling a 12 oz. mug with espresso instead of coffee – it’s the same amount of liquid in the cup, but the espresso is much more potent. As a result of the error, the patient unintentionally injected himself with five times more insulin than intended.

The overdose could have been fatal, but the patient, who had been managing his diabetes for quite some time, was able to recover after eating foods high in sugar to normalize his blood sugar. He remembers, “It was the scariest moment of my life.”

Upon learning what happened, the prescribing physician called the pharmacy to discuss what went wrong. He also found an alternative option: a high dose of insulin prescribed with a pen. The correct concentration of insulin is already inside the pen, so the opportunity for error is minimized.

At the Brigham, we are recommending changing our electronic ordering system to direct providers to the pen when they are placing an order for high-dose insulin.

In addition, I’ve shared this key learning with safety leaders at the pharmacy where this occurred, other pharmacies, and the Institute for Safety Medication Practices, a medication error group, which sends national alerts and identifies patient safety trends, with the aim of reducing the potential for harm to patients across the country.

As part of our commitment to transparency, we will continue to share stories about errors at Brigham Health and what we’ve done to prevent similar errors from happening again.

Have you experienced a medical error?  We’d like to hear from you.


One thought on ““The Scariest Moment of My Life”

  1. Bill Donaldson

    Karen –

    Kudos to Brigham for continuing their transparency on quality issues. Great job of simplifying the case to the learning moments.

    Hopefully, your recommended changes to the ordering system will be adopted before another error occur. Obviously there is an economic impact and insurance payment of prescribing the pens that is part of the decision process.

    Probably omitted for length and clarity was the pharmacy’s response. Why doesn’t the pharmacy move the U-500 syringes next to the U-500 insulin to make errors harder occur. A poka-yoke (mistake proofing) system would bundle a ‘standard’ set of syringes with every vial of insulin when they are received at the pharmacy. The pharmacist would remove the excess or add any short fall syringes when filling the prescription and return/take them to the U-500 stock. Ideally Lilly would have a mated vial that would only accept the U-500 syringe.

    Keep living and sharing the stories of “Just Culture”

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