A One Thousand Unit Mistake

Medication errors are a leading cause of hospitalization and prolonged hospital stays. Insulin is especially infamous as a high risk medication in terms of safety. This case demonstrates that even very large mistakes with insulin can occur easily. Safety protocols must be in place for high risk medications like insulin. Unfortunately not all mistakes are prevented even with these safeguards. In this case there were multiple reasons leading to the medication error. Even when a medication safety committee examines what they see as every possibility for a mistake, human error is underestimated, as was the case with this individual.