ISMP Brazil alerts on confusion between insulin and vaccines

April 30, 2016 - On this D Day of flu immunization in Brasil, awareness is needed on confusion between insulin and vaccines as stated by an ISMP Brasil Alert following a serial error that occurred last Thursday 28 April 2016 in the community hospital of Maringá (North Paraná) where fifty employees received a dose of insulin by error instead of the influenza vaccine.

The nurse in charge of the vaccination of the hospital staff took the wrong box in the refrigerator where insulin and vaccine against influenza were stored. She has been confused with the packaging and administered the wrong substance to her colleagues and to herself. The administration of vaccines began at 9 am, and the error was spotted around 10am. Given the error, staff members who have been "vaccinated" with insulin received a glucose injection. To avoid problems, all were hospitalized and remained under observation until 21h. So far, fortunately, no employee showed any adverse effects.

ISMP Brasil Alerta-vacina 2016 04 29

Although having already alerted healthcare professionals about the risks of errors involving vaccines in a bulletin on insulins and on neuromuscular blockers, ISMP Brasil takes advantage of a National Safety Alert on this confusion between insulin and influenza vaccines occurrence to highlight the need for learning front of the internally identified errors and other health institutions; and to present some recommendations to prevent medication errors involving vaccines.

It is unfortunate that these errors continue to occur while they are long known: similar mix-ups between vaccines and insulin have led to the deaths of 21 children in 1997, others have been reported and published:

World Health Organization "Global manual on surveillance of adverse events following immunization" 2014; page 21.
Institute for Safe Medication Practices (ISMP) "What else is stored in a refrigerator with influenza vaccine?" ISMP Medication Safety Alert! Acute Care 2014; 19 (24): 1.
Shanks L et coll. "Learning without Borders: A Review of the Implementation of Medical ErrorReporting in Medecins Sans Frontieres" PLoS One 2015; 10 (9): e0137158.

And fatal confusions involving muscle relaxants are more serious and more worrying. The International Medication Safety Network (IMSN) has made it the starting point of its International Position Statement on Safer Vaccine Packaging and Label Design, calling on 14 December 2015 for greater worldwide attention to the problem of unsafe design of vaccine packaging and labelling.

Although without serious consequences for the health professionals who were the subject of this vaccination campaign, the error that occurred in Brasil recalls the urgency to understand and implement the proposals of the IMSN. Again and again, the IMSN position statement calls on healthcare professionals, pharmaceutical companies, technology vendors, professional organizations, and regulatory/standard-setting organizations to help improve vaccine safety and efficacy. Read on...

The New Zealand safe use of opioids collaborative

The Health Quality & Safety Commission New Zealand is running an 18-month formative collaborative to reduce opioid-related harm in hospitals.

The collaborative aim is to reduce opioid-related harm by 25 percent in district health board* (DHB) hospital’s participating areas, and build capability in medication safety and quality improvement methodology.

The collaborative began in September 2014 and ends in April 2016.
Opioids were chosen for the collaborative because of the associated harm identified in incident reports and a global trigger tool study done in three DHBs (1). The Institute for Healthcare Improvement’s (IHI) collaborative methodology (2) is being used and the IHI is providing external advice.

Participation in the collaborative is voluntary. All 20 DHBs and one private hospital are taking part. Only 18 of the multidisciplinary teams are actively testing interventions using plan-do-study-act cycles. The other three teams are engaged and learning the methodology. Teams include a consumer whenever possible.
Team members in individual hospitals are not funded. The Commission’s national collaborative team provides leadership, guidance and support through visits, phone calls and webinars. The Commission hosted four regional learning events as part of the initial engagement approach. Three national learning sessions when teams come together to learn and share have been hosted and up to three team members from each DHB were funded to attend.

Teams have used local findings to choose the opioid-related harm and the target ward(s) to work on. Most are aiming to reduce harm from opioid-related constipation, but there are teams focusing on respiratory depression, uncontrolled pain and nausea and vomiting.

It is anticipated that a bundle of evidence-based interventions will be identified by the end of the collaborative for implementation in any hospital area.
The formative collaborative is being independently evaluated. This has been ongoing and learnings are considered throughout.
Further information and learning session materials are available on the Commission’s website.

* A district health board is responsible for providing or funding the provision of health services in their district. Disability support services and some health services are funded and purchased nationally by the Ministry of Health.


  1. Seddon ME, Jackson A, Cameron C et al. The Adverse Drug Event Collaborative: a joint venture to measure medication-related patient harm. NZMJ 2013; 126 (1368): 9-20.
    Read on...
  2. Institute for Healthcare Improvement. The Breakthrough Series: Institute for Healthcare Improvement’s (IHI) Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. 2003. Read on...


IMSN Position Statement on Safer Design of Vaccines Packaging and Labelling

14 December 2015 - The International Medication Safety Network (IMSN) has issued a position statement that calls for greater worldwide attention to the problem of unsafe design of vaccine packaging and labelling. The statement calls on healthcare professionals, pharmaceutical companies, technology vendors, professional organizations, and regulatory/standard-setting organizations to help improve vaccine safety and efficacy.IMSN PS Vaccine cover

The IMSN statement provides recommendations, including:

  • Packaging that minimizes the need to prepare individual doses, provides unit dose according to the mode of administration, and redesigned vials (where vials are still used) to accommodate larger labels.
  • Labelling that uses larger fonts for better readability; adoption of World Health Organization Vaccine Presentation and Packaging Advisory Group (WHO VPPAG) expiration dates standard; provision of peel-off labels to facilitate syringe labelling; and improved differentiation of pediatric and adult formulations.
  • For vaccines provided with diluents or two component vaccines:
    -- Packaging that forces proper mixing of the diluent or of the two components of the vaccine; for example a two-chambered syringe or vial. If not feasible, vials of vaccine and diluent or second component should be packaged together without prejudice of storage requirements.
    -- Provide clear instructions in or on the label for mixing components of vaccines requiring
    reconstitution. Display directions and warning to administer contents of both vials together on the front label of each carton, vial, and vial cap. The label of diluents must primarily identify them as such and make it clear they are not the actual vaccine. For example, “DILUENT for preparing” followed by name of vaccine. Place warning on diluents that they are not the actual product.
  • Healthcare authorities and regulators should promote safer labelling and packaging of vaccines and make available recommendations to healthcare providers for safer vaccination practices.

Vaccine manufacturers are strongly encouraged to revise packaging and labelling as specified, with particular attention on vaccines with diluents or two-component vaccines. For a complete copy of the position statement, click here.