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ISMP Canada News

June 11, 2014: Reported Confusion with Insulin Syringe Labelling

ISMP Canada recently received a near-miss incident report involving an incorrect insulin dose due to confusion related to labelling of insulin syringes.

In this incident, a nurse interpreted a label reading “0.5 mL/cc” on the BD 0.5 mL insulin syringe to mean “0.5 mL per cc” (cubic centimetre). This confusion led to preparation of an incorrect dose. As a result, a BD 1 mL insulin syringe labelled with “1 mL/cc” was used instead, as this label was thought to be less confusing. The 1 mL/cc syringe seemed more intuitive to use, which allowed a correct dose to be drawn up, and subsequently avoided a medication error.

Both syringes also had “U-100 Insulin” printed on them, and it was later determined that none of the healthcare professionals at the site had a clear understanding of the intended meaning of “U-100. ” The reporter wanted to broadly share this information so that others could be alerted, in the hopes that similar incidents would be prevented.    Read more...