16 Indiana students hospitalized after getting Insulin instead of TB skin test.

[NRSKarenRN, BSN, RN]

Looks like the five rights of medication administration not followed. Since this is a career school, why was insulin (usually single student's medication) kept in same area as Tuberculosis skin test vial - which requires refrigeration? Will be interesting to see if licensed nurse or health assistant involved in this medication error.

When administering TB tests at the hospital & later in home health agency, each person's administration form had TB brand and lot number written on permission form --which would have triggered nurse to realize that wrong vial picked up. Karen

16 Indiana students hospitalized after getting shot with insulin by mistake

10/1/18 ABC News

Sixteen students at an Indiana career center were hospitalized after they were accidentally injected with shots of insulin during what was meant to be a tuberculosis skin test, the school district said....

...The insulin shots were administered during the tuberculosis test with medical personnel from the Community Health Network...

..A spokeswoman with the school district told ABC News on Tuesday that all the students had since been released from the hospital.

[AnonymousSuper]

This is easy to make a snap judgement about.

This deserves a root cause analysis.

[TriciaJ, RN]

I'm curious whether the syringes were pre-drawn up by someone to save time.

I've seen people almost accidentally use TB syringes instead of insulin syringes, which is why they should be stored separately and clearly labeled. But to substitute insulin for PPD is a new one by me.

[crazin01]

On 4/20/2020 at 7:46 PM, TriciaJ said:

I'm curious whether the syringes were pre-drawn up by someone to save time.

I used to give PPD's annually for employee health at a smaller hospital. And I would always pre-draw the PPD's to save time when staff were present. However, I was the only one with access to them and there were no other medications in that refrigerator/cooler at remote sites.

Most recently at a detox/rehab facility, all nurses would administer PPD's on an almost daily basis. Again, night shift would pre-draw a certain amount, but insulin was kept in a different area. But we would use insulin syringes interchangably for PPD syringes, as there were often issues with supplies. Given they're both 1cc syringes, it seems common practice. I've also had a few other colleagues confirm they do the syringe swap, only as a last measure...