1. Cohen, Michael R. RPh, MS, ScD

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Does your facility store insulin vials inside the opened carton that came from the pharmacy? If so, stop.

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Vials may be accidentally returned to a mismatched carton after use, setting the stage for a serious insulin mix-up if the next nurse identifies the product by the outer carton instead of the label on the vial. To prevent patients from getting the wrong insulin product, the pharmacy should discard external packaging cartons before dispensing insulin vials or the nursing unit should discard the cartons when the vials are received in the unit. This should be done whether the vials are labeled for individual patients or placed into unit stock.