Medication Errors
Michael R. Cohen ScD, MS, RPH

July 2011 
Volume 41  Number 7
Pages 12 - 12
  PDF Version Available!

At a clinic, a Lilly insulin pen and HumaLOG insulin cartridge was dispensed to a patient for home use. Several days later, the patient was treated in the ED for hyperglycemia. As part of their evaluation, ED personnel examined the patient's insulin pen to determine if it was empty or defective. They found that instead of an insulin cartridge, the pen contained a teaching cartridge filled with saline. The patient was treated and returned home with no further consequences.The HumaLOG insulin cartridge has red bands on both ends with red lettering; the saline cartridge has black bands with black lettering. But when a cartridge is put into this pen device, you can't see the drug name or the banded colors that differentiate the two cartridge types.The manufacturer provides the pens in an unsealed box, which means that a teaching pen with a saline cartridge could accidentally be placed in the box. To improve safety, clinic staff now open every box of pen devices they receive for a visual check

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