Insulin Instead of Flu Vaccine Given to Residents and Staff at
Oklahoma Intermediate Care Facility
Recently EMS and fire crews responded to an emergency call at an Oklahoma care facility regarding one unresponsive person. Upon arrival they found 10 persons exhibiting similar symptoms, including several that were unresponsive. Two of the 10 were employees of the facility. Due to their disabilities, the residents could not explain their issues, and the fire crews set about trying to determine the cause of the problem.
It was discovered that the residents and the employees were scheduled to receive flu shots that day from a local pharmacist and he had, in fact, given them their injections. However, upon further checking by EMS and fire crews, it was discovered that the pharmacist had mistakenly injected insulin instead of the flu vaccine.
All 10 of the persons receiving the injections were hospitalized, and several had to remain in the hospital due to the long-acting effects of the insulin injections.
The investigation is ongoing and the pharmacist who is not an employee of the facility is cooperating fully with the police. It is not known if any further steps will be taken by the police, but the police believe it was an accident.
Compliance Perspective
Failure by a facility to ensure that persons administering medications are qualified medical personnel who know and follow the “rights” for administering medication may result in a significant medication error and the provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding the administration of medications to residents and employees (where applicable) to ensure that medically qualified persons are perform such tasks as giving flu vaccine injections.
- Train staff regarding the importance of following medication administration protocols in order to prevent medication errors.
- Periodically audit to determine if personnel administering medications are complying with the required safety processes with each resident.
