CHPSO Patient Safety Alert: Insulin and Influenza Vaccine Switched 50 Hospital Employees in Brazil Given Insulin Instead of Influenza Vaccine
On April 30, 2016, fifty employees at a Brazilian hospital
received a dose of insulin instead of the influenza vaccine.
The vaccine and the insulin were stored in the same refrigerator,
and were retrieved by a staff member who confused the two
similar-looking vials. The staff member took the wrong box from
Those who received the incorrect, influenza-portioned injection
of insulin were hospitalized. No adverse events have been
Always separate look-alike vials and clearly label.
Differentiation is key.
Similar events have occurred in the US with a mix-up of
influenza and other vaccines, and insulin.