| Contents | Previous | Next |
A nurse who was supposed to give a combined dose of NPH and regular insulin went to the refrigerator where insulin vials were stored. She took one vial from the NPH box and another from the regular box, then drew up 40 units of NPH and 6 units of regular. The solution should have been cloudy. But it was almost clear, so she suspected that something was wrong.
She examined the insulin vials and discovered that someone had placed them in the wrong boxes. So the nurse had actually drawn up 40 units of regular and 6 units of NPH insulin.
We've discussed this before, but it bears repeating: Don't rely on a vial's storage container or box, a shelf label, or the label on a bin or drawer. Always read the label on the drug vial itself. If possible, throwaway the boxes and store only the vials