10 People Got Insulin Instead Of The Flu Shot

Flu clinic
Copyright - 2018 Portland Press Herald

It’s de ja what bleep all over again. Just a month ago, I wrote for Forbes about how 16 students in Indianapolis, Indiana, had accidentally been given insulin when they thought that they were getting tuberculosis tests. Then on Wednesday, Saundra Adams reported for KTUL that 10 patients at the Jacquelyn House in Bartlesville, Oklahoma, who were supposed to have gotten the flu shot, instead ending up receiving guess what? No, not the flu shot, because that wouldn’t have been news.

The answer begins with “in”, ends with “in”, and has a “sul” in the middle. Yes, insulin. Once again, people received insulin when they were not supposed to receive the medication.

Adams quoted Bartlesville Police Chief Tracy Roles as saying, "EMS and fire crews arrived shortly after and found not one unresponsive person, but multiple unresponsive people. All these people are symptomatic, lying on the ground, needing help, but can't communicate what they need." This sounds terrible. The following video from Time described the facility as one where “people with intellectual disabilities were hospitalized”:

The video also stated that the “facility had contracted with an experienced pharmacist to administer the influenza vaccine.”

This wasn’t just a little oopsie, like being served sweetbreads when you had ordered bread pudding. Getting insulin when you are not supposed to can be a very, very serious error. How serious? Well, insulin, whether it is the naturally occurring hormone or a synthetic version of it, stimulates the cells in your body to take up sugar from your blood stream. Too much insulin can make your blood sugar levels drop too low. That can make you feel light-headed and woozy. It can make you pass out and even throw you into a coma. It can in some cases be life-threatening.

How then do you avoid accidentally giving insulin to people? How about reading and double-checking the label? You know the one that says “insulin” on it? The Cleveland Clinic provides a list of different types of injectable insulin formulations:

  • Insulin glulisine (Apidra®)
  • Insulin aspart (Novolog®)
  • Insulin lispro U-100/U-200 (Humalog®)
  • Regular insulin (Novolin R, Humulin R)
  • NPH insulin (Novolin N, Humulin N)
  • Insulin detemir (Levemir®)
  • Insulin U-100 (Lantus®, Basaglar®)
  • Insulin glargine U-300 (Toujeo®)
  • Insulin degludec U-100/U-200 (Tresiba®)
  • Pre-mixed insulin 70/30 (70% N and 30% R) or 50/50 (50% N and 50% R)
  • Pre-mixed insulin: Humalog® mix 75/25 (75% NPL and 25% insulin lispro) or Humalog® mix 50/50 (50% insulin lispro protamine and 50% insulin lispro) or NovoLog® mix 70/30 (70% insulin aspart protamine and 30% insulin aspart)

Notice how none of these insulins are named “flu shot” or “tuberculosis test.”

It’s unclear what exactly caused the blunder in Bartlesville. Was it just carelessness by the pharmacist or did the environment or circumstances somehow contribute to the errors? Was the pharmacist overworked and overstretched? Were the medication bottles in some way mislabeled? Did the mistake occur at the supplier level, the pharmacy level, or the pharmacist level? How were the bottles stored? Were the flu vaccines close to the insulin? Did anyone double-check what the pharmacist was doing? As they say on Twitter, I have so many questions. There aren’t enough details available to know what exactly went wrong.

Regardless, this and the incident in Indianapolis show once again that health care is very different from most other industries. A screwed up order in the fast food or apparel industries is typically a lot more obvious and a lot less serious. If a store sent you a thong instead of a winter jacket, you won’t just put it on and wonder why you are so cold outside. You’d probably notice the error immediately or at least when you can’t find the sleeves. Whereas, with health care, you as a patient may not readily recognize when a mistake has occurred until it is too late. And you could suffer a lot more than just embarrassment.

That’s why you should make sure that any health care facility that you use hires properly trained professionals who have enough experience and will conscientiously double- and even triple-check everything that they are doing. Avoid facilities that try to cut costs by hiring just anyone to do the work. Beware of facilities that don’t have proper mechanisms in place to prevent errors such as people to double-check someone else’s work. Watch out for facilities that overwork or overstretch their health care professionals so that errors are more likely. As we have seen, even something as seemingly simple as administering the flu shot requires proper attention. If a health care facility and its administration believes that health care professionals are no more than interchangeable commodities, such insolence can lead to something like insulin being given when it shouldn’t.

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It’s de ja what bleep all over again. Just a month ago, I wrote for Forbes about how 16 students in Indianapolis, Indiana, had accidentally been given insulin when they thought that they were getting tuberculosis tests. Then on Wednesday, Saundra Adams reported for KTUL that 10 patients at the Jacquelyn House in Bartlesville, Oklahoma, who were supposed to have gotten the flu shot, instead ending up receiving guess what? No, not the flu shot, because that wouldn’t have been news.

The answer begins with “in”, ends with “in”, and has a “sul” in the middle. Yes, insulin. Once again, people received insulin when they were not supposed to receive the medication.

Adams quoted Bartlesville Police Chief Tracy Roles as saying, "EMS and fire crews arrived shortly after and found not one unresponsive person, but multiple unresponsive people. All these people are symptomatic, lying on the ground, needing help, but can't communicate what they need." This sounds terrible. The following video from Time described the facility as one where “people with intellectual disabilities were hospitalized”:

The video also stated that the “facility had contracted with an experienced pharmacist to administer the influenza vaccine.”

This wasn’t just a little oopsie, like being served sweetbreads when you had ordered bread pudding. Getting insulin when you are not supposed to can be a very, very serious error. How serious? Well, insulin, whether it is the naturally occurring hormone or a synthetic version of it, stimulates the cells in your body to take up sugar from your blood stream. Too much insulin can make your blood sugar levels drop too low. That can make you feel light-headed and woozy. It can make you pass out and even throw you into a coma. It can in some cases be life-threatening.

How then do you avoid accidentally giving insulin to people? How about reading and double-checking the label? You know the one that says “insulin” on it? The Cleveland Clinic provides a list of different types of injectable insulin formulations:

  • Insulin glulisine (Apidra®)
  • Insulin aspart (Novolog®)
  • Insulin lispro U-100/U-200 (Humalog®)
  • Regular insulin (Novolin R, Humulin R)
  • NPH insulin (Novolin N, Humulin N)
  • Insulin detemir (Levemir®)
  • Insulin U-100 (Lantus®, Basaglar®)
  • Insulin glargine U-300 (Toujeo®)
  • Insulin degludec U-100/U-200 (Tresiba®)
  • Pre-mixed insulin 70/30 (70% N and 30% R) or 50/50 (50% N and 50% R)
  • Pre-mixed insulin: Humalog® mix 75/25 (75% NPL and 25% insulin lispro) or Humalog® mix 50/50 (50% insulin lispro protamine and 50% insulin lispro) or NovoLog® mix 70/30 (70% insulin aspart protamine and 30% insulin aspart)

Notice how none of these insulins are named “flu shot” or “tuberculosis test.”

It’s unclear what exactly caused the blunder in Bartlesville. Was it just carelessness by the pharmacist or did the environment or circumstances somehow contribute to the errors? Was the pharmacist overworked and overstretched? Were the medication bottles in some way mislabeled? Did the mistake occur at the supplier level, the pharmacy level, or the pharmacist level? How were the bottles stored? Were the flu vaccines close to the insulin? Did anyone double-check what the pharmacist was doing? As they say on Twitter, I have so many questions. There aren’t enough details available to know what exactly went wrong.

Regardless, this and the incident in Indianapolis show once again that health care is very different from most other industries. A screwed up order in the fast food or apparel industries is typically a lot more obvious and a lot less serious. If a store sent you a thong instead of a winter jacket, you won’t just put it on and wonder why you are so cold outside. You’d probably notice the error immediately or at least when you can’t find the sleeves. Whereas, with health care, you as a patient may not readily recognize when a mistake has occurred until it is too late. And you could suffer a lot more than just embarrassment.

That’s why you should make sure that any health care facility that you use hires properly trained professionals who have enough experience and will conscientiously double- and even triple-check everything that they are doing. Avoid facilities that try to cut costs by hiring just anyone to do the work. Beware of facilities that don’t have proper mechanisms in place to prevent errors such as people to double-check someone else’s work. Watch out for facilities that overwork or overstretch their health care professionals so that errors are more likely. As we have seen, even something as seemingly simple as administering the flu shot requires proper attention. If a health care facility and its administration believes that health care professionals are no more than interchangeable commodities, such insolence can lead to something like insulin being given when it shouldn’t.

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I am a writer, journalist, professor, systems modeler, computational and digital health expert, avocado-eater, and entrepreneur, not always in that order. Currently, I

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