Answers demanded after flu jab mixup

vaccine vaccination needle

Stakeholders are shocked after 10 people in one US town were believed to have been given insulin instead of flu vaccinations by an experienced pharmacist

CBS affiliate KOTV reported that eight residents of a Bartlesville, Oklahoma group home for people with intellectual disabilities, and two staff members, were hospitalised after having what they believed were vaccinations against influenza.

According to local police, health practitioners attended the Jacquelyn House to give flu shots, but they believe that insulin shots were given instead.

Police say that the person who administered what was believed to be influenza vaccines was a very experienced pharmacist who has been a member of the profession for 40 years. The pharmacist was not an employee of the facility.

“At some point, and we don’t know how it happened yet, the vial that contained the flu vaccine was traded out for a vile containing what we believe to be insulin,” Bartlesville Police Chief Tracy Roles told KOTV.

Police said that a 911 call was received at about 4.30pm on Wednesday, November 6, saying a person at the facility was “unresponsive” while the Barnstable Patriot reports that multiple people were found in this condition.

The first responders noticed that other people were suffering similar symptoms but the residents had difficulty communicating with them.

“All these people are symptomatic, lying on the ground, needing help, but can’t communicate what they need,” Bartlesville Police Chief Tracy Roles said in an interview. “That’s why I give a lot of praise to the fire and EMS staff for doing an outstanding job of identifying the problem.”

Mr Roles said told WGCL that he had “never seen where there’s been some sort of medical misadventure to this magnitude” but was thankful that the outcome was not worse.

“The person who administered what we believe is insulin is being very cooperative,” he told KOTV.

“Not being evasive or elusive at all. I’m so hopeful that means that this was just a terrible accident.

“The bigger hope is that all of the patients who are at the hospital make a full recovery.”

All of the patients were treated by Jane Phillips Hospital and subsequently released.

Health writer Bruce Y Lee wrote in Forbes that the misadventure was “de ja what bleep all over again,” as he had written only a month ago that 16 students in Indianapolis, Indiana had been given insulin instead of tuberculosis tests.

“Once again, people received insulin when they were not supposed to receive the medication,” he wrote.

“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 then do (sic) avoid accidentally giving insulin to people? How about reading and double-checking the label? You know the one that says ‘insulin’ on it?

“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.”

An investigation is underway.

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1 Comment

  1. Christine Kincaid

    If that was an insulin mix-up; how were the vaccine lot numbers & expiration dates transcribed from the vaccine vial onto the patient’s permanent health record or EHR? Did the pharmacist administer injections that a tech drew up?

    Hypoglycemic seizures are a known adverse reaction to the actual flu vaccine. Are we sure this was a mix up?

    And why are both of these recent events a supposed mix up with insulin? Cardizem is refrigerated. So is Risperidone, among many others. How do you manage to only have mistakes with the only other med that would cause hypoglycemic seizures?

    Insulin vials are not labeled INsulin. They are labeled Humalog or Novulin with a big ‘N’ or ‘R’ on the label. It’s not like you could misread INsulin for INfluenza.

    Multi-dose influenza vials are in 5ml vials & the dose is 0.5 ml; meaning 10 patients exactly could be vaccinated from the actual influenza vaccine vial, while these ‘mistakes’ in documentation would have to happen TWICE with TWO 3 ml insulin vials to dose 10 people.

    Each patient supposedly received 50 UNITS of insulin & nobody is in the ICU or died?

    Something is not right here.

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