Caught a major med error today!


So...I'm going about my business today in the world of homecare nursing, and I sit down to do my patient's insulin prefill for her. Her pharmacy (which shall remain nameless) sends her 3 boxes of her Novolin 70/30 vials every month but tapes them together under one label as one months worth of insulin. With me so far? Well today I opened the second box to get out the second vial as the first vial had been emptied and discarded last week. I'm about to start filling syringes when something stopped me- couldn't put my finger on it at first- then I realized that the insulin was clear. Wait a second! 70/30 is cloudy. Took a look at the label on the actual vial and sure enough--Nololin R. Ripped off the prescription label taping the three boxes together- sure enough, pharmacy delivered 1 box of 70/30 and 2 boxes of Novolin R, all under the script label of Novolin 70/30 :eek:

Called her pharmacy, spoke to pharmacist. He's like "well that's not good". Anyway, I ran to the pharmacy (2 blocks over) and exchanged for the right insulin. All I could think of was...ok, if x amount of people die from med errors every year...this could have been one of them (her 70/30 dose is over 40 units BID-- imagine if she took 45 units of the Novolin R! :eek::eek::eek:)


43 Posts

Specializes in Hospice, Ortho/Neuro Rehab, camp nurse. Has 2 years experience.

Holy cow! Thank god you noticed. As a Type 1 Diabetic I would have been down and out. Thank you for being a responsible Nurse who checks. Diabtes is a quick lecture in school.

Specializes in Pediatrics.

I'm also Type 1 and rarely take more than 30 units in a day! Thank you keeping an eye out for your patient.


686 Posts

Specializes in Health Information Management.

Jeez Louise! Thank goodness you were paying attention! Good catch. :bow:


1,237 Posts

Specializes in critical care, PACU. Has 2 years experience.

good job!


450 Posts

Specializes in NeuroICU/SICU/MICU.

Good catch!

I'm just a student, but I found a pharmacy error for one of my dad's antihypertensive medications. They had filled it at half the prescribed dose. Needless to say, we went right back in to get it fixed. Blood pressure meds (and insulin, for that matter!) are not meds to mess around with.

Specializes in Neuroscience/Neuro-surgery/Med-Surgical/.

yikes and great job for finding the error!!!

I once found a pharmacy of my meds. When I was 12. I take ritilin back then I was on 20 mg's though I took it in 2 10mg tabs. well we got a new script I was about to take a dose. I look at it in my hand and it did not look right to me. I call my mom and we take it to a different pharmacy to ask about it. they had given me 20mg tabs but the directions on the bottle still said take 2 so I would have taken 40mg's had I taken it. the pharmacist was impressed with me for noticing at that age.


72 Posts

Kudos to you for catching that!!! As a soon to be student it def reminds me to check, double check, and triple check EVERTHING...Thanks for sharing your story; it reminds me to be vigilant :idea:


28 Posts

Specializes in Home Health.

good job for catching that error!